1. State of Michigan State Burn Coordinating Center Mass Casualty Plan EMS Education Module Michael T. Long, RN, BSN, MS, EMT-P

2. 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

3. 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

4. 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

5. 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)

6. 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

7. Close Calls July 15, 2009 – Hazel Park, MI – I-75 and Nine Mile Rd – Gas tanker accident and explosion – Subsequent bridge collapse

8. 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

9. 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

10. 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 3 rd 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

11. 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/

12. 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

13. 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

14. 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

15. Burn Triage Chart

16. 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”

17. 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

18. 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

19. Treatment Fluid Resuscitation (Parkland) Dressings

20. 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

21. 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 D 5 LR if and when available USE THE FORMULA – Fluids are NOT “wide open” – Consider use of IV pumps

22. Parkland ‘cheat sheet’ Thanks to North Carolina Burn Surge Disaster Program

23. 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

24. 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

25. 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

26. 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

27. Extended scene care Consider forming treatment teams – IV start team – Pain control team – Fluid resuscitation team

28. 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