View Full Version : Triage and Burn Treatment

01-20-2013, 06:28 AM
Okay in my work-in-progress, my heroine has been burned in from an explosion cause by a bomb. She wasn't close enough or exposed long enough to suffer third-degree burns but she does have second-degree burns and some shrapnel in her. Now I know usually following a massive disaster like the one I've got in my book, the medical crew are going to be doing triage (taking only the most seriously injured to the hospital while trying to treat as many at the scene as possible), but I kind of need to know what kind of treatment would they be giving her at the scene until they can get her to a hospital. I've tried scouring Wikipedia but I'm not sure. So can anyone help me out?

01-20-2013, 06:51 AM
The extent of thermal burn coverage and specific sites involved are often at least as important as the degree of burn. The main issues are potential shock, inhalation injuries, dehydration, and infection, with the first two being the most pressing.

Basics are:

1) Separate from the source of heat, with concomitant neck & spine precautions. This may involve removing material from the surface of the skin.

2) Airway, Breathing, Circulation -- basic resuscitation first aid

3) Look for signs of inhalation injury: charcoal-colored nasal discharge or sputum, singed or missing facial or nose hairs, hoarse voice, burn or swelling of the face, and altered mental status. Any of these bump you up in priority, as inhalation injury can be a silent killer. Any of these also earn you supplemental oxygen if available, even if you seem to be breathing fine.

4) Remove watches, bracelets, rings, clothing that binds, anything that can cut off blood supply as tissue swells. Tight things will get tighter and can act as tourniquets to blood supply.

[Added: This is also where the site of the burn comes in, as circumferential burns around any of the limbs can put one at heightened risk of "compartment syndrome," where the swelling of the tissue itself compresses its own arterial blood supply.]

5) Cool the thermal burn area by temporarily immersing in cool (not icy) water, as the burn will continue to progress until cooled.

6) Evidence of impending shock earns you elevated limbs and likely IV fluids, if available. Or even just if the burn area is more that 20% of total body surface area, often estimated by rule of 9s (http://www.who.int/surgery/publications/Burns_management.pdf) (see illustrations on pages 2 and 3 of this WHO pdf). Any thermal burns totaling >15% of total body surface area can mean enough fluids are lost--because a main function of skin is to prevent loss of fluids--to put one into shock. If it's a risk, often an IV line is put in anyway, as it's much easier to get in before the veins collapse.

7) Pain control

8) Wrap in clean dry sheets and blankets if needed. Monitor carefully for progression of signs and symptoms. The general rule is to "cool the burn but warm the patient."

People used to be wrapped in wet sheets, but that is generally best avoided now for longer term, as it advances the risk of hypothermia. What general timeframe is the story set in? That will affect the standard protocols used.

Added: Shrapnel is another issue, of course.

01-20-2013, 03:41 PM
From my very limited experience, presence of shrapnel will bump her up the triage 'queue', so to speak. She's 'walking wounded' so she won't be #1 priority ("T1" - patients who require immediate, life-saving treatment) and likely not a #2 priority ("T2" - patients who need significant treatment in a timespan of around 2-3 hours) Depending on the scale and severity of the burns and shrapnel wounds, she'd probably be a T2 or T3 ('delayed priority' - a patient who does need treatment, but can wait a while.)

this (http://www.patient.co.uk/doctor/Trauma-Triage-and-Scoring-(ATLS).htm) is a good resource on post-trauma triage.

In terms of actual treatment, Pyekett's got you covered. Priority with blast injuries is to nullify the risk of hypothermia. IV fluids are given only if the paramedics are certain there's no internal injuries, but this will be a priority as well. If your character is suffering any kind of respiratory distress, they'll provide oxygen. This (http://emergency.cdc.gov/masscasualties/blastinjuryfacts.asp)is a good source of information on blast injuries.

01-21-2013, 12:33 AM
"Triage" means "prioritize." (That may not be the literal definition, but it is an effective idea of the definition)

Essentially how quickly any specific person will be treated depends on a few factors.

1. How severely they are injured
2. How many OTHER people are also injured
3. What resources are available on-site (at the location or the hospital later) to treat these people.

What I'm saying is "triage" is a dynamic decision making process.

If there are only a few people injured, everyone will be treated sooner, with the most critical seen first.

If it is a true mass casualty situation, priority goes to those who can still be saved, but who would die without immediate treatment. After that the less serious injuries would be treated. If there are too many injured, and not enough first responders, it's entirely possible her treatment at the scene might be limited to a quick visual look and a "Here, hold this on the wound" as someone hands her a dressing and goes to take care of someone else more critically injured.

Btw, I believe you are mistaken in one assumption. Eventually EVERYONE will be taken to the hospital, unless they refuse treatment and leave the site under their own power. The triage is about who will be taken first. First responders are not equipped to handle multiple burns and shrapneal injuries outside of emergency stabilization and immediate transport to the hospital.

It comes down to, what will work best for your story? You can justify her being seen earlier, or later, or slipping away untreated, depending on how you set up the scenario. Figure out what you want to have happen to her and then write the scenario to match.