Mass casualty burn triage

Overview

Burn mass casualty incidents (BMCIs) present unique challenges that exceed the capacity of standard mass casualty triage systems. Burns require prolonged, resource-intensive specialized care concentrated in a limited number of burn centers. Standard prehospital triage protocols such as START (Simple Triage and Rapid Treatment) do not account for the unique injury patterns, delayed deterioration, and resource demands of thermal injuries ^[1][2]. Effective BMCI response requires burn-specific triage algorithms, pre-established surge capacity plans, and coordinated regional and national patient distribution systems ^[3][4].

Triage Systems

Limitations of Standard MCI Triage for Burns

Standard MCI triage systems (START, SALT, Sieve) assess casualties using vital signs, mental status, and ambulatory ability. These systems do not incorporate burn-specific variables such as TBSA, burn depth, inhalation injury, or age-adjusted mortality predictions ^[2][5]. Bazyar et al. reviewed 20 different primary adult triage systems worldwide and found no universal agreement on how burn patients should be triaged in mass casualty situations ^[2]. Neal et al. developed the "-PLUS" prehospital triage system to supplement existing rapid triage protocols with mechanism-specific algorithms for burns, blast, chemical, and radiation injuries ^[5].

Burn-Specific Triage Algorithms

Ng et al. implemented a burn-specific mass casualty triage system during the 2015 New Taipei City powder explosion, using consciousness, breathing, and burn size as triage modifiers. The system demonstrated 93.9% sensitivity and 86.7% specificity for predicting ICU admission, with an under-triage rate of 6.3% and over-triage rate of 4.2% ^[6]. By comparison, sorting the same population with START showed 100% sensitivity but only 53.3% specificity, indicating that START over-triages burn casualties ^[6].

Outcomes-to-Resources Triage Tables

Taylor et al. generated data-driven burn triage tables from the National Burn Repository, stratifying patients by age, TBSA, and inhalation injury status into resource categories: expectant (predicted mortality over 90%), low, medium, high, very high, and outpatient ^[7]. Inhalation injury significantly altered triage categories; for patients over 70 years, expectant status began at 50% TBSA without inhalation injury but dropped to 40% with inhalation injury. These updated tables reflect improvements in burn care since previous iterations and are designed for use in disaster resource allocation ^[7].

Disaster Planning

Burn Center Surge Capacity

Kearns et al. outlined the essential components of a burn mass casualty disaster plan, including coordination, communication, triage, plan activation triggers, surge capacity, and regional capacity assessment ^[4]. Planning occurs at three levels: institutional/intrafacility, interfacility/intrastate, and interstate/regional. The 2005 ABA burn disaster guidelines recognized that local and state assets are the most important resources in the initial 24 to 48 hours ^[4].

Mobile Burn Teams

Potin et al. described the Swiss burn plan rationale, proposing deployment of mobile burn teams from referral burn centers to disaster scenes. These teams bring specialized skills to the prehospital setting, assist with primary and secondary triage, contribute to initial patient management, and advise non-specialized hospitals on acute care of patients with TBSA under 20% to 30% ^[8]. Key requirements include socioeconomic feasibility, streamlined logistics, and partnership with military resources.

European Response Framework

Almeland et al. developed a European burn mass casualty response plan within the EU Civil Protection Mechanism, prompted by the 2015 Romanian nightclub fire. A survey of European burn centers found that 71% had existing mass casualty response plans but only 35% had burn-specific plans ^[9]. The European plan provides burn assessment teams for specialized in-hospital triage, coordinated specialized burn care across European centers, and medevac capacities from participating states ^[9].

Canadian Experience

Fuchko et al. conducted a case study of BMCI preparedness in Alberta, finding that existing policies were limited to all-hazards planning and did not address the specialized needs of burn patients. Identified deficiencies included no burn-specific plan at either of the province's two burn centers, no provincial-level recognition of BMCI challenges, and no established Canadian burn disaster communication plan ^[10].

Military Burns and Combat Casualty Care

King, Cancio, and Jeng reviewed burn management in military mass casualty settings, where concomitant blast injuries, chemical exposures, and austere environments complicate triage and treatment. Stabilization, triage, and follow-on care of these patients require local, state, and often regional coordination ^[3].

Key Planning Principles

Effective BMCI planning requires ^[4][8][9]:

• Pre-established activation criteria: Clear triggers for plan activation based on casualty numbers and severity
• Regional burn bed inventory: Real-time or near-real-time awareness of available burn beds across a region
• Communication protocols: Standardized communication among burn centers, emergency management, and transport agencies
• Patient tracking: Systems for tracking patient distribution across receiving facilities
• Supply chain: Pre-positioned burn-specific supplies (topical agents, dressings, fluids)
• Workforce surge: Plans for extending burn nursing and surgical staff through non-burn-trained personnel with just-in-time training

Controversies and Evidence Gaps

No triage system has been demonstrated as superior for burn mass casualties based on patient clinical outcomes, scene management improvement, or resource allocation optimization ^[2]. Most BMCI plans have not been tested in actual events; evidence comes largely from retrospective analysis of individual incidents. The optimal TBSA threshold for expectant triage remains controversial and changes with advances in burn care outcomes ^[7]. Coordination between civilian and military burn assets for domestic disasters is not well developed in most countries. The role of telemedicine in real-time BMCI triage is theoretically promising but operationally unproven at scale ^[5][10].

References

[1] Kearns RD et al. (2017). Disaster Preparedness and Response for the Burn Mass Casualty Incident in the Twenty-first Century. Clin Plast Surg. 44(3):441-449. PMID: 28576233 [2] Bazyar J, Farrokhi M, Khankeh H (2019). Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach. Open Access Maced J Med Sci. 7(3):482-494. PMID: 30834023 [3] King B, Cancio LC, Jeng JC (2023). Military Burn Care and Burn Disasters. Surg Clin North Am. 103(3):529-538. PMID: 37149388 [4] Kearns RD et al. (2014). Disaster planning: the basics of creating a burn mass casualty disaster plan for a burn center. J Burn Care Res. 35(1):e1-e13. PMID: 23877135 [5] Neal DJ, Barbera JA, Harrald JR (2010). -PLUS prehospital mass-casualty triage: a strategy for addressing unusual injury mechanisms. Prehosp Disaster Med. 25(3):227-36. PMID: 20586016 [6] Ng CJ et al. (2018). Introduction of a mass burn casualty triage system in a hospital during a powder explosion disaster. World J Emerg Surg. 13:38. PMID: 30181768 [7] Taylor S et al. (2014). Redefining the outcomes to resources ratio for burn patient triage in a mass casualty. J Burn Care Res. 35(1):41-5. PMID: 24270085 [8] Potin M et al. (2010). Mass casualty incidents with multiple burn victims: rationale for a Swiss burn plan. Burns. 36(6):741-50. PMID: 20185244 [9] Almeland SK et al. (2022). Burn mass casualty incidents in Europe: A European response plan within the European Union Civil Protection Mechanism. Burns. 48(8):1794-1804. PMID: 35987741 [10] Fuchko D, King-Shier K, Gabriel V (2024). Burn mass casualty incident planning in Alberta: A case study. Burns. 50(5):1128-1137. PMID: 38461081