State of MichiganState Burn Coordinating Center

Mass Casualty PlanEMS Education Module

Michael T. Long, RN, BSN, MS, EMT-P

Background/History

• Michigan has so far been spared many of the major burn/trauma disasters of the past few decades– 9/11– Rhode Island Nightclub

fire– West Virginia mine

explosions– Oklahoma City bombing

• However, there have been significant incidents in the past

• Several close calls• PLENTY of potential

Historical Disasters• October 8-19, 1871

– Four fires, three in Michigan (fourth was Great Chicago Fire)

– Altogether killed more than 1700 and burned millions of acres

• September, 1881– Sanilac County– Killed 300 and displaced 14,000– 1480 barns, 1521 homes, 51

schools burned• 1908

– Metz Fire– 32 killed

• More recently– 2007, Sleeper Lake fire– No casualties, but

approx. $7.5 million to suppress

• Still great potential for wildfires and forest fires, especially in Upper Peninsula and northern Lower Peninsula

Historical Disasters• May 18, 1927

– Bath, MI– Domestic terrorism, school

dynamited– 42 killed (33 were children)

• December, 1971– Port Huron, MI– Lake Huron water tunnel explosion– 22 dead, 11 injured (including 6

critical and 2 EMS responders)

• August 16, 1987– Northwest Flight 255– One survivor, 4 year old girl with

major burn injuries• July 1997

– Charlevoix, MI– Venetian Festival fireworks

explosion– 1 dead, 17 injured

• December 1998– Osseo, MI– Independence Professional

Fireworks Company explosion– 7 dead, 13 injured– 4 dead in explosion at same site 3

months later

Historical Disasters

• February 1, 1999– Ford Rouge Power Plant

explosion– 6 dead, 24 injured

– http://www.bwcc.nl/images/FordRouge.jpg

• April 12, 2000– Egelston Township

(Muskegon), MI– Chemical plant explosion– 10 injured (2 critically)

Close Calls

• September, 1990– Bay City, MI– M/V Jupiter tanker

explosion

– http://www.bwcc.nl/images/FordRouge.jpg

• June 7, 2000– Blackman Township

(Jackson), MI pipeline rupture

• August 9, 2005– Romulus, MI chemical

plant explosion

Close Calls

• July 15, 2009– Hazel Park, MI– I-75 and Nine Mile Rd– Gas tanker accident and

explosion– Subsequent bridge

collapse

Potential Events• Power plants

– Nuclear• Donald C. Cook, Bridgman,

MI• Fermi II, Monroe, MI• Palisades, South Haven, MI• Big Rock Point, Charlevoix,

MI (decommissioned)• Fermi I, Newport, MI

(decommissioned)• Ford (Phoenix Memorial

Lab), University of Michigan, Ann Arbor, MI (decommissioned)

• Power Plants– Coal

• 88 across state, from White Pine and Ontanogan in UP to Erie and Monroe near the Ohio border

– Natural gas• Several dozen across

state, although many underutilized or dormant

• New construction expected as costs of coal fired plants increases

Potential Events• Mines

– Tilden and Empire iron mines in UP

– 4 gypsum mines– 4 salt mines

• Petroleum/Natural Gas/Renewables– One major refinery

• Marathon, Detroit, MI– 4 ethanol plants– 4 biodiesel plants

• More of both coming soon– Dozens to hundreds of

petroleum and natural gas wells

– Hundreds of miles of petroleum and natural gas pipelines

– Dozens of natural gas-producing landfills

Potential Events• Sporting event venues

– Superior Dome (aka “Yooper Dome”) at Northern Michigan University

– Football stadiums and basketball/hockey arenas on nearly every university campus

– Pontiac Silverdome (reopened)– Van Andel, Joe Louis, and

Palace arenas– Ford Field– Comerica Park– Michigan International

Speedway• 3rd largest “city” in state on race

weekends

• Points of interest– Mackinac Bridge, Ambassador

Bridge, Bluewater Bridge– St. Clair Tunnel, Windsor

Tunnel– Renaissance Center– Selfridge ANG base

From Arrival to Prolonged Field Care

• 25-30% of expected casualties in any disaster will be burns or have a burn component

• The average victim will have a >50% TBSA burn

• Initial field management will play a large role in the survival of these patients

David L. Ryan/Globe Staff/File 2003

thtp://www.boston.com/news/local/articles/2008/09/21/the_cost_of_tragedy/

From Arrival to Prolonged Field Care

• While the hope is that most patients will be transported within the first few hours, EMS personnel could conceivably be called on to provide prolonged care in the field for burn victims

Arrival• Scene size-up• Scene safety

– You can’t help if you just became a patient, too

• Establish incident and/or medical command– First on scene, last off

scene• National Incident

Management System (NIMS) guidelines

Triage

• Mass burn casualty triage is somewhat similar to typical mass incident triage

• In the face of limited resources, patients who are the most salvageable should receive priority, not the most severely injured

Burn Triage Chart

Burn Triage Chart• Outpatient=Green or

“Walking Wounded”• High=Red or “Immediate

Transport”• Medium=Yellow or

“Delayed Transport”• Low=Yellow/”Delayed

Transport” or Black/”No Transport”

• Expectant=Black or “No Transport”

Treatment

• “Low” or “Expectant” does NOT mean no treatment!– Expect to have to task

staff to provide pain control and/or sedation for these patients

– Resources may open up at a later time to provide inpatient care

Treatment

• “High” and some “Medium” patients should receive treatment and transport priority to a surge facility

• Size of the event may dictate transport priority– For example, patients

with a ~50% TBSA burn in the teens to 40’s age range would be transported early in a small incident, but may be triaged as delayed or no transport in a larger incident

Treatment

•Fluid Resuscitation (Parkland) •Dressings

Parkland Formula

Adult• 2-4 mL fluid per kg body

weight per percent TBSA burned

• Give ½ the amount in the first 8 hours

• Give remaining ½ in the next 16 hours

• Example: A 100 kg patient has a 30% TBSA burn. – 4 mL * 100 kg * 30=12,000 mL– Give 6 liters in the first 8 hours– Give remaining 6 liters over

next 16 hours

Pediatric• 2-3 mL fluid per kg body

weight per percent TBSA burned

• Same distribution of fluid over time

Parkland Formula

• LACTATED RINGER’S– Other crystalloids pose a

high risk of electrolyte imbalance, which contributes to edema

– EXCEPT peds, who are more likely to become hypoglycemic, so use D5LR if and when available

• USE THE FORMULA– Fluids are NOT “wide

open”– Consider use of IV

pumps

Parkland ‘cheat sheet’

Thanks to North Carolina Burn Surge Disaster Program

Dressings

• Use DRY dressings– Even on burns as “little”

as 10% TBSA, wet or moist dressings can cause hypothermia

– Hypothermia can kill a burn patient as readily as hypovolemia or infection

Transport• In a mass casualty

situation, patients will need to be transported to surge facilities

• These facilities may not be where burn patients are normally transported per local protocols

• However, the surge facilities will receive the supplies, personnel, and support to treat burn injuries until more definitive care becomes available

Transport• Coordination with incident

command, surge facilities, and the State Coordinating Center will be key to prevent overloading facilities

• State Burn Coordinating Center: U-Michigan, Ann Arbor

• State Burn Coordinating Center-Alternate: DMC, Detroit

Extended scene care

• Ideally, all casualties will be transported within 1-2 hours and no more than 5 hours

• However, size and location of incidents and availability of surge resources may dictate extended on-scene treatment

http://www.boston.com/news/weather/gallery/katrina_refugees?pg=19

AP photo

Extended scene care

• Consider forming treatment teams– IV start team– Pain control team– Fluid resuscitation team

Extended scene care

• If on-scene treatment becomes prolonged out to 8 hours or more, EMS may need to transport medical staff from the hospitals for more involved procedures– Foley placement– Wound debridement– Antimicrobial dressings

• Silvadene