Recommendations for burns care in mass casualty incidents: WHO Emergency Medical Teams
Technical Working Group on Burns (WHO TWGB) 2017-2020
Amy Hughes
a,b,c, Stian Kreken Almeland
d,e, Thomas Leclerc
g,h,
Takayuki Ogura
i, Minoru Hayashi
j, Jody-Ann Mills
k, Ian Norton
l,m,n, Tom Potokar
a,f,n,*
aInterburns,InternationalNetworkforTraining,EducationandResearchinBurns,Swansea,Wales,UK
bHumanitarianandConflictResponseInstitute(HCRI),UniversityofManchester,UK
cCambridgeHospitalNHSFoundationTrust(Addenbrookes),PaediatricICUDepartment,UK
dDepartmentofPlastic,HandandReconstructiveSurgery,NorwegianNationalBurnCenter,HaukelandUniversity Hospital,Bergen,Norway
eFacultyofMedicine,UniversityofBergen,Norway
fCentreforGlobalBurnInjuryPolicyandResearch,SwanseaUniversity,Wales,UK
gBurnCentre,PercyMilitaryTeachingHospital,Clamart,France
hVal-de-GrâceMilitaryMedicalAcademy,Paris,France
iJapaneseSocietyforBurnInjuries,TheDisasterNetworkCommittee
jJapanesesocietyforburninjuries,TheAcademicCommittee
kRehabilitationProgramme,DepartmentofNCD,WorldHealthOrganization,Geneva,Switzerland
lWorldHealthOrganization(2013-2019),EmergencyMedicalTeamInitiativeLead,Geneva
mRespondGlobal,Queensland,Australia
nCo-ChairWorldHealthOrganizationEMTTechnicalWorkingGrouponBurns,Geneva
abstract
Healthandlogisticalneedsinemergencieshavebeenwellrecognised.Thelast7yearshas witnessedimprovedprofessionalisationandstandardisationofcarefordisasteraffected communities ledinpartbytheWorldHealthOrganisationEmergencyMedicalTeam(EMT) initiative.
Masscasualtyincidents (MCIs)resultinginburninjuriespresent uniquechallenges.
Burn management benefits from specialist skills, expert knowledge, and timely availability of specialist resources. With burn MCIs occurring globally, and wide varianceinexistingburncarecapacity,theneedtostrengthenburncarecapabilityis evident.Althoughsomehigh-incomecountrieshavewell-establisheddisastermanage- mentplans, includingburnspecificplans, many donot themajorityofcountries whereburnmasscasualtyeventsoccurarewithoutsuchestablishedplans.Developing article info
Articlehistory:
Accepted2July2020
Keywords:
Burns
Masscasualtyincidents
Emergencymedicalteams(EMTs) Recommendations
* Correspondingauthorat:CoChairWHO-EMTTechnicalWorkingGrouponBurns;CentreforGlobalBurnInjuryPolicy&Research;
SwanseaUniversity;Wales;UK.
E-mailaddresses:[email protected](A.Hughes),[email protected](S.K.Almeland),[email protected] (T.Leclerc),[email protected](T.Ogura),[email protected](M.Hayashi),[email protected](J.-A.Mills),
[email protected](I.Norton),[email protected](T.Potokar).
https://doi.org/10.1016/j.burns.2020.07.001
0305-4179/©2020The Authors.Published by ElsevierLtd.This is anopen access articleunderthe CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Availableonlineatwww.sciencedirect.com
ScienceDirect
j our na l hom e pa g e : ww w. e l s e v i e r. c om/ l o ca t e / bur ns
globally relevant recommendations is a first step in addressing this deficit and increasingpreparednesstodealwithsuchdisasters.
Globalburnexpertswereinvitedtoa successionofTechnicalWorkingGrouponburns (TWGB)meetingsto:
1)reviewliteratureonburncareinMCIs;and
2)defineandagreeonrecommendationsforburncareinMCIs.
Theresulting22recommendationsprovideaframeworktoguidenationalandinternational specialistburnteamsandhealthfacilitiestosupportdeliveryofsafecareandimproved outcomestoburnpatientsinMCIs.
©2020TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY- NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Healthandlogisticalneedsinemergencieshavebeenwell recognised [1]. The last seven years has witnessed an improvingprofessionalizationandstandardisationofcare for disaster affectedcommunities a changewhich has beenbroughtaboutinpartbytheWorldHealthOrganiza- tion Emergency Medical Team (WHO EMT) initiative [2].
Since its origin in 2013, this initiative has provided a platform forthe evolutionanddevelopment ofspecialist EMTs,strengtheningspecifichealthandlogisticalresponse inemergencies.Nationalcapacitystrengtheninghasbeena focus, with particular resources targeted to building National EMT specialist teams. The initiative supports and encourages trained and appropriately skilled teams of national and international personnel to deliver a co- ordinatedapproachtotargetedhealthneedswhilstadher- ingtominimumstandardsofcare.Theevolvingnature,and changing definition, of humanitarian emergencies has highlightedthe needfor a widenedscope of practicefor EMTs. In addition to EMT’s influentialrole in outbreaks, conflictand chroniccomplexdisasters, smaller scale but highimpactemergencieshavealsobroughttoattentiona needforspecialistEMTsabletotargetspecifichealthneeds [3,4].
MCIs resulting in burn injuries present some unique challenges [5,6]. Accounting for at least 200,000 deaths annually,burninjuriesandtheresultantmorbidity,mortali- ty,anddisabilityrankhighasaglobalpublichealthproblem [7,8]. With high prevalence in low and middle-income countries,non-fatalburnsareamongtheleadingcausesof DisabilityAdjustedLifeYears(DALY)lost[9].Burnmanage- ment of those injured requires specialist skills, expert knowledge, andtimely availabilityof specialist resources.
Lack of immediate (on-scene) patient care and the con- sequencesofpoorearlydecision-makinginpatientmanage- ment can impact significantly on patient outcome and capability of health facilities to deliver good burns care [10].MCIswithmultipleburninjuredpatientshavedemon- stratedtheextensivedemandsplacedonhealthcarework- ers and local health facilities and the resultant high morbidity and mortality rates. With burn MCIs occurring globally,andthewidevarianceinexistingburncarecapacity indifferentpartsoftheworld,theneedtostrengthenburn carecapabilityisevident.
1.2. Internationaltechnicalworkinggrouponburns (TWGB)
In accordancewiththeprocessesused tocreateminimum standardsofcareamongsttheemergingEMTspecialistteams, a numberofglobal burn and EMT expertswere invitedto participateinasuccessionofTechnical Working Groupon burnsconsensusmeetings(TWGB).AllEMTworkinggroups are convenedby WHO underthe auspicesof theStrategic AdvisoryGroup(SAG)oftheEMTInitiative.ThisSAGassists theWHO EMTsecretariattoidentifygapsandpriorities for workand ismadeup ofrepresentativesfromMinistriesof Health.Opinionsfromeachofthe6regions,aswellasUNand representativesfromNonGovernmentOrganisations(NGOs) and the Red Cross and Red Crescent movement, are represented.
TheTWGBwasgiventermsofreferenceandatimebound periodtocompleteitsworkoftwoyears.Expertscamefroma range of countries and geographic regions, were gender balanced, andrepresented nationalhealthauthorities,aca- demic institutions, professional bodies, NGOs and the Red CrossRedCrescentmovement,WHOandmilitaries.
Theaimsofthisworkwere:
1)Reviewtheliteratureonburninjuriesandmanagement inMCIs;and
2) define and achieveagreement amongst theEMT and globalburnscommunityonrecommendationsforburncarein MCIs.
Theresulting recommendations aremeant toprovidea frameworktoguidenationalandinternationalspecialistburn teams and health facilities to ensure delivery of safe, appropriate,andrelevantcaretoburnpatientsinthecontext ofamasscasualty.
Athree-stagedapproachwasundertaken:
1 Acomprehensiveliteraturesearchwasperformedusinga numberofsearchterms.Inaddition,relevantcitedpapers fromcitationlistsweresourced.
2 AseriesofTWGBconsensusmeetingswereheldto facilitatediscussionandconsensusbuilding.Intotalfour TWGBmeetingswereheldoveran18monthperiod. 3 Atwo-phasesurveywasconducteddetailingeachofthe
proposeddraftrecommendationsandcirculatedtothe EMTandwiderburnscommunityforfeedback.The resultsofthesurveycanbefoundathttps://interburns.
org/survey.
1.3. TWGBconsensusprocess
Step1
MembersoftheTWGBundertookacomprehensivelitera- turesearch.Evidencewascollatedfrombothpublishedand
‘grey’ literature.Inaddition, guidelinesandtechnicaldocu- mentsacrossthehumanitariansectorwereconsulted.
Step2
Burnexpertsfromavarietyofcontexts,andwithsignificant rolesintheclinicalcareofburn-injuredpatients,wereinvitedto jointhefirstTWGBmeetingatTheCentreforGlobalBurnInjury Policy & Research in Swansea, December 2017. The main deliverablesincludeddraftinganinitialsetofrecommendations based on experiential practice and evidence from the literature on burn careinMCIs.TWGB representativesincludedthoseinvolved inburncarenursing,rehabilitation,surgicalcareandcommuni- ty-basedcarewithextensiveworkingpracticebothwithintheir homecountriesandinemergencyresponse.Expertopinionwas weightedheavilywhendraftingtherecommendations.
Step3
Led by the TWGB consultant, a technical document stating the recommendations and rationale for each was drafted and circulated to TWGB members for comment. In addition, a comprehensive survey detailing the recommendations and rationalewasdistributedtothewiderEMTcommunitywitha requestto‘agree;partiallyagree;ordisagree’oneachrecom- mendation.Commentswereinvitedtoproviderationaleforeach answerprovided,andtohelpcontributetoonwarddiscussions.
Step4
Aheadofthe2ndTWGBmeeting(July2018,WHO,Geneva), resultsfromthe survey werecollatedand revisions tothe technicaldocumentfromTWGBmemberfeedback andthe surveyweremade.Furtherdiscussionsand consensuswas undertaken,withparticularfocus onviewsand comments capturedinthesurvey.
Step5
Arevisedsurvey,retainingthesameformatbutreflecting thechangesafterthe2ndTWGBdiscussions,wascirculatedto thewiderEMTcommunityandinternationalburnorganisa- tionsforcomment.
Step6
The third TWGB meeting was hosted in New Delhi (November 2018). Results from the revised survey were presentedanddiscussedinadditiontorevisionofanumber ofdraftrecommendations.Followingthe TWGBmeeting,a penultimateiterationofthetechnicaldocumentwascirculat- edtoTWGBmembers.
Step7
ThefinalTWGBmeetingwashostedinmeeting Bergen, Norway(Nov2019)toaddressanypointsrequiringclarification andagreefinalrecommendations,inadditiontodiscussions aroundimplementationandtraining.
2. Background and overview
2.1. Aetiologyofmasscasualtyincidentswithburninjuries
BurninjuryfrequencyfollowingaMCIshouldnotbeunder- estimated. The nature of burn injuries often results in a
protractedclinicaljourneyforthepatient,commonlyresulting in long-term health consequences affecting functioning, qualityoflifeandmentalhealth.Burnpatientsalsoriskbeing stigmatisedbycommunities[7,11]
Table 1 captures some of the most recent global MCIs resulting in burn injuries [12 19]. The end column highlightstheconstraintsandchallengesidentifiedduringthe MCI response and from which anecdotal evidence was considered whenevolvingthe recommendationspresented inthispaper.
2.2. Settingstandardsinburncare
Standardsettinghasprovenacrucialstrategyforhealthcare systemstrengthening,improvingpatientsafetyandimprov- ingqualityofcare[20].Asburncarecapabilityacrosshealth facilities varies globally, providing guidance tostandardise anddefinelevelsofburncareavailableorrequiredwithina health facility helps provide a platform for strengthening responsetoburnscareinMCIs
In 2012 Interburns (International Network for Training, Education & Research in Burns) hosted an international consensus meeting to define basic, intermediate and ad- vanced levels of burn care in terms of knowledge, skills facilities andequipment. Theselevels ofcarereflect those most often found across the globe, but in low resource environmentsthereisasignificantlackofbothintermediate andadvancedlevelsofcarewhichfurtherhampertheabilityto respondtoaburnMCI.Theroleofspecialistburnsteamsisto bolsterthecapacityofburnscaretomeetlocalneedsinan emergencyscenario[20].
2.3. Evolvingspecialistburnteams
TheTWGBidentifiedtheneedfortwotypesofspecialistburn teamstoreflectthephasesofresponsefollowingaburnMCI:
˗ BurnRapidResponseTeam(BRRT);and
˗ BurnSpecialistTeam(BST).
Countriesmayhavecapabilitytosupportdevelopmentof oneorboth typesofteam,with BRRTslikelyto be moreprevalent andhaveastrongernationalpresencethanspecialistteams.
2.3.1. Burnrapidresponseteam(BRRT)
Asmallteamofseniorburnexperiencedhealthcareworkers and logisticians aiming to deploy within 6 12 h. The timelinessrequiredfortheBRRTsupportsanationalpresence offeringhomeandregionalresponse.TheroleofBRRTsisto support the immediate and early phase of burn care, specificallydefinitivetriage,clinicalassessment,andtheco- ordination of patient distribution to hospitals within the country. Supportive roles may also include: resource and clinical assessment; clinical advice and support; decision making;technicaladvice; co-workingwithlocalauthorities and the Health Emergency Operations Centre (H-EOC) to supportreferralandtransferofpatients;resourceassessment anddistribution;andliaisoncommunication.
BRRTsareexpectedtoworkcohesivelywithhealthcare workers at the receiving hospitals and with local health
Table1–ConstraintsandchallengesidentifiedfromMCIsresultinginburninjuries.
Masscasualtyincident Aetiology Estimatednoofburn injured
Identifiedconstraintsandchallenges
‘WhiteIsland’volcaniceruption;New
Zealand;2019
Volcanic Eruption
47 (21dead)
Theon-goingseismicandvolcanicactivityinthe areaaswellasheavyrainfall,lowvisibilityand toxicgaseshamperedrecoveryefforts
Volcanicinhalational(ashandgas)andthermal burnsrequiredcomplexmanagement
Supportrequiredforadditionalresources(e.g.
deceaseddonorskin) MBUBAgastankerexplosion,2018,DRC[12] Truckcaughtfire
postcollisionand siphoningof gasoline
125 On-scenetriageminimal Transportfromscenevariable
Firstreceivinghospitals20kmand110kmfrom scene
Overburdenedhospital limitedbeds,fewcon- sumablesforburndressings
Localhealthcarestaffinexperiencedinburnscare Delayedspecialistburnteamdeploymentdueto
visarequirement
Higheracuitycare(e.g.ICUbeds)limited FuegoVolcanoeruption,Guatemala,2018
[13]
Volcanic eruption
>200 Surgeeffectofpyroclasticdensitycurrents(PDC)
fromeruptions;PDCmechanismofburnsandthe impactofPDCflowinurbanisedareas
Multipledailyexplosionsgeneratingashplumes driftingkmsfromvolcano inhalationaland thermalburns
Challengesofmassevacuation Highnumberofinhalationalinjuries Limitedburncareresources GrenfellTowerFire,2017,UK[14] Originoffire
electricalfault refrigerator fire spreadsecondary topoorfireretar- dantexternal cladding
140 Firespreadrapidlysecondarytocombustible exteriormetalcompositematerialpanels Highrisebuilding,challengingaccessandegress Noautomaticfiresprinklersystem
FormosaFunCoastParkColourParty,2015, TaiwanSAR[15]
Ignitionofcol- ouredpowder
499 Delayedrecognitionofinhalationalinjurieson scene
Overloadedtransportrequirementfromscene
‘Walkingwounded’unabletomobilisefromscene
duetopain
Transferstrategyachallenge directtransfer fromscenetospecialisedcentresforburn patientsdifficultduetolimitedburncare capacities
Localcapacitiesofburncarequickly overwhelmed
Kunshanfactoryaluminiumdust explosion,China[16]
Flameindust filledworkshop usedtopolishcar wheelhubs
230 Patientssenttoneighbouringcitiesfortreatment Temporaryburntreatmentcentreestablished
Colectivnightclubfire,2015,Romania[17] Fireworksre- leasedinsideclub
144 (64died)
OverburdenedlocalhospitalsinBucharestand IlfovCounty internationalsupportrequiredfor burnbeds
Infectioncontrolchallenges TazreenFashionsfactory,2013,Bangladesh
[18]
Faultyelectrical installations;
poorelectrical safety
>200 (112died)
Difficultaccesstohighrisebuilding,patients trapped
Blockedandlockedexitdoors Stampede
emergencymanagers tosupport co-ordinationof the burn responseandpatientdistribution.BRRTsarerecommendedto remainin-situforonlyashortperiodoftime,withintegration intotheburnspecialistteam(BST)ifrequired.Alargeburn incidentwouldlikelybenefitfrommorethanoneBRRT.
2.3.2. Burnspecialistteam(BST)
Acomprehensiveburnsteamcomprisedofabroadermixof experiencedburn healthcareworkers and logisticians. The BSTmaybe nationalor international, aiming toprovide a longerdurationofsupporttotheburnresponseandsupple- mentthesupportprovidedbytheBRRT.Arrivalincountrymay be48 72h(orlonger)aftertheinitialincidentandBSTsare recommendedtoremainin-situforupto6weeks.Theroleof BSTsistoprovidedirectclinicalassistanceinmanagingthe highcaseload.BSTsarelikelytobetaskedtoanadvancedburn service,ifoneexists,ortothehospitalwherethemajorityof patientsarebeingtreated.Veryrarelyitmaybenecessaryto establishanentirelyseparatefieldhospitaltosupporttheBST.
BRRTsandBSTsshouldbeself sufficient,andadhereto minimumstandardsandcoreprinciplesofcareasdefinedin the ‘BlueBook’ (Classificationand Minimum Standardsfor ForeignMedicalTeamsinSuddenOnsetDisasters,[1]).
3. Recommendations
Therecommendations,finalisedafterconsensusfromboththe TWGBdiscussionsandresultsofthesurveys,arecategorised
under a number of key themes. Each recommendation is detailedcomprehensivelywithrationaleprovidedforeach.The themeshavebeenidentifiedbytheTWGBasbeingcrucialto effectiveburncareinMCIsandwhereminimumstandardsof careshouldbedelivered(Fig.1).
Part 1: Patient distribution, flow and triage
Patientdistributionfromthescene,andonwardpatientflow, hasbeenclearlyevidencedasbeingintegraltoefficientuseof healthresourcesandimproved patientoutcomeinMCIs[21,22].
Asimpleandapplicablepatientflowdiagram,capturingthe pointsdetailedbelowandforuseintheeventofaMCIwith burn injured, was constructed by the TWBG. This can be viewedinthe‘infographic’developedbytheTWGBmembers in 2019 reflecting all of the recommendations: : https://
interburns.org/assessment/#consultancy.
On-Scene(thesiteoftheincident):
Firstrespondersmayincludepassers-by,localcommunity members,emergencyservicepersonnelandhealthcare workers.
Immediatefirstaidand‘on-scene’triageshouldoccur.
Patientsshouldbemovedfromscenetothefirstreceiving hospital/s.Patientsmaybemovedbyanyformoftransport available.
Table1(continued)
Masscasualtyincident Aetiology Estimatednoofburn injured
Identifiedconstraintsandchallenges
MountMerapivolcano,Yogyakarta2010 and1994[19]
Volcanoeruption >200 Challengesinforecastingthetype,magnitude andtimingofdestructiveexplosiveeruptions Uncheckedpopulationexpansionimpactingon
disasterplanning
Surgeeffectofpyroclasticdensitycurrentsfrom eruptions;PDCmechanismofburnsandthe impactofPDCflowinurbanisedareas
Challengesofphasedevacuationduetorapidand unpredictableescalationofvolcanicactivity Directwarningsfromthevolcanoobservatory
stafftothepopulationineffectivebecausethe hollow-logdrumattheobservatorypostwasin disrepairandnosirensinstalled
PDCresultinginextensivethermalandinhala- tionalburnsandasphyxiationfrominhalationof volcanicash
Journeytimefromincidentsitetohospital25km (approx.2hours)
Noprehospitaltriageinplace
MainhospitalinYogyakarta(DrSardjitoHospital) overwhelmedbynumbersofpatients(sixbedson burnunitonly)
Earlycausesofdeathlaryngealoedema;cardio- vascularshockandacuterespiratoryfailure;
renalfailure.;Highnumberofvictimsand patientssufferedinhalationalinjuries;lackof respiratorysupply
Poorprotectiveclothingforvoluntarysearchand rescueteams
Ahealthpost(localclinic)shouldbeconsideredan extensionofthesceneandnotjudgedahospital.
Immediatefirstaidand‘on-scene’triageisrecommended followedbytransferofpatienttoafirstreceivinghospital.
Patientsmayself-present(immediatelyordelayed)toa healthpostorhospital.
FirstreceivingHospital/s
Isdefinedasthehospital/sreceivingpatientsfromthe sceneorpatientswhoself-present.
On-goingclinicalcare,‘on-arrival’,and‘definitivetriage’
shouldoccuratthefirstreceivinghospitalpriortoany decisionaboutpatientonwardreferralbeingmade.
Designatedfirstreceivinghospitalsshouldbeeithera districtlevel(preferential)oratertiarylevelhospital.
Burncarecapabilitywithinfirstreceivinghospitalswill vary.Tohelpstandardisethelevelofburncareafirst receivinghospitalcandeliver,andsupportthefacilityin achievingthis,taskingofBRRTandBSTcanoccur.
Decisionsregardingreferralandtransferofpatientswho meetthedefinedclinicalcriteriashouldoccuratthefirst receivingfacilityoncedefinitivetriagehasbeen
undertaken.
Patientswhohaveselfpresentedorbeenmovedfrom scenetoatertiaryhospitalinthefirstinstance,andwho havesustainedburninjurieswhichdonotrequire specialistburncentrecare,shouldbere-distributedto othernonspecialistfacilities.Thisprocesssupports decongestionofspecialistburnfacilities(e.g.availabilityof burnbeds;intensivecarebeds).
Anytransferofapatientbetweenhospitalsshouldonly occuroncethepatientisclinicallystableenoughfor transfer,andappropriatecommunicationbetweenrefer- ringandreceivinghospitalhasbeenundertaken.
Decision-makingregardingtransferofpatientscanbe difficult.BRRTandBSTsarewellplacedtosupportthis process.
ReferralHospitals(thosereceivingreferredpatients)
ReferralHospitalscanbetertiaryordistricthospitals.
Tertiaryhospitalsarerecommendedtoreceivepatients whowillbenefitfromspecialistandhigheracuityburns care.Districthospitalshowevermayalsoactasreferral hospitalsandsupportadecongestionmechanismby receivingpatients(fromtertiaryhospitals)whodonot requirespecialistburnservicesbuton-goingloweracuity burncareisindicated.
AnimportantroleofBRRTandBSTsistohelpimplement ascaleupofresources(surgecapacity)andhelpsupportan advanced burn care capability, particularly in referral hospitals.
Triage(On-scene) Recommendation1
OnScene:Conventionaltriagesystemsshouldbeutilisedon scenetodeterminelife threateningtraumainjuries.
Recommendation2
OnScene:Estimationofburnseverityshouldfocusmainlyon Total BurnSurfaceArea (TBSA)estimationand notinclude depthassessment.
InaMCIinvolvingfireorexplosion,bothtraumaand/or burninjuriesmayresultandarapidassessmentandtriageof injuriesisindicated[23].Thefirstresponderpoolwillbevaried in their experience ofassessing injuredpatients and thus guidance should be familiar, simple and practical in its approach.
Existingandconventionaltriagesystems(suchasSTARTor MIMMSTriage)shouldbeimplementedinthefirstinstanceto identify life-threatening injuries (Priority 1) such as those compromisingtheairway(includinginhalationalburnsaswell asheadandneckinjuries),breathing(suchascircumferential Fig.1–TWGBRecommendationthemes.
full thickness chest burns), or injuries causing massive haemorrhage, and patients assigned an appropriate triage category[22].
Followingconventionaltriage,assessmentofburninjury severity can occur. On-scene assessment of burn severity shouldbedeterminedfromTotalBodySurfaceArea(TBSA) estimationasscenerespondersmaynotbeexperiencednor trainedincomprehensiveburninjuryassessment.Depthofa burnwillchangeovertimeandcanbedifficulttoassesseven byburnsspecialistsinthefirst24hours[24].
EstimationofTBSAonscenesupportsasimplebutearly effectiveapproachtoinitialburntriage.However, overand underestimationofTBSAislikelyon-scene,andenvironmen- talandculturalconstraintsmayimpactonhoweasilyTBSA estimationcanoccur[6].Thus,reassessmentandre-triageon arrival atthe first receivinghospital, and subsequentlyby burn-experiencedstaff,isessential.
Mortality from burns is multifactorial, although the relationshipbetweenTBSAand survivaliswellknownand wasfirstnotedin1902[25].
Survivabilityfactorssuchasage, depthandsiteofburn,andpatientco-morbiditiesshouldbe consideredinconjunctionwithTBSAestimationfromthefirst receivingfacilityonwards.Recommendation3
Onscene:thefollowingcategoriesarerecommendedforburn injurytriage:(Table2).
Recommendation3isapplicabletolow,middleandhigh- incomecountriesinanapproachtostandardiseandsimplify on-scenetriageofburninjuriesacrossallcontexts,andwith consideration to local resource availability. As over and underestimationofTBSAislikelytooccuronsceneRecom- mendation3supportsacautiousapproachtoallocationinto Green(P3),Yellow(P2)andRed(P1)categories[6].
Inhalationinjury
First responders, and those at the initial receiving health facility,areadvisedtobeobservantforthe earlysignsand symptoms of a thermal inhalational injury. Inhalational injuriescancause significant morbidityand mortality[26].
Earlyrecognitionandinterventionoflikelyairwaycompro- mise or respiratoryfailure isanimportantstep inhelping improvepatientoutcome.Signsofinhalationalinjuryinclude soot in the mouth, facial burns, stridor, hoarseness and confusion.
Thetypeofincidentandmechanismofburninjurywill also provideadditionalindications toriskof inhalational injury.Evidencesuggeststhatfailuretorecogniseactualor
pendingairwaycompromisefrominhalationalburnsearly increasesmortalityratesignificantly[6,27].Findingsfroma threestagedmixmethodsstudyfollowingtheburnMCIin Taiwan (2015) identified that patients with inhalational injuries were prone to be under-triaged when first res- ponders usedthe Simple andSTART triage toolsand no burn injury specific triage tool was used. Those with inhalational burns rapidly developed airway obstruction and hypoxiawhilst awaitingtransportation. The authors recommendedthatevaluationofinhalationalinjurybean integral part of triage procedures and evaluation of inhalational injury the most critical step in the triage process[6].
Consideration should alsobegiven to the possibility of chemical inhalationalinjuriessuchasthoseresultingfrom mustard gas, phosphorus and chlorine following MCIs.
Appropriatepersonalprotectiveequipmentisadvisedwhen managingpatientssuspectedofbeingvictimsofachemical incidentandanawarenessoftheoftendelayedeffectsofthe agent is important (e.g. Mustard agents) [28]. Industrial accidents can also give rise to inhalational injuries for examplecyanidepoisoningfromacrylics[29].
Inhalational injury impacts significantly on patient outcome [6,30].
However, early and appropriate interven- tionsandreferralofsuchpatientstospecialisedburncentres can help support improved outcome. Early interventions include airway protection, oxygenation andcautiousfluid management. Advanced airway management (intubation andventilation)isresourceintenseandthusconsideration at the earliest possible phase of care should be given to onwardplanningofpatientcare.Consideringthecomplexity ofpositivelydiagnosinginhalationinjuryeveninspecialised settings,itislikelythatfirstresponderswilloftenmissthe condition. Careful re-assessment at the first receiving hospitalisthereforeparamount.Recommendation4
On Scene: ‘Non-survivable’ triage category should not be implementedonscene,onlyatthefirstreceivinghospital.
Due to the dynamic nature of TBSA estimation and potential on-scene TBSAestimation error, decision-making regarding survivabilityofaburninjuryisrecommendedto occuratthefirstreceivinghealthfacility,ideallyunderexpert guidance.Survivabilityfactorssuchaspatientage,patientco- morbidities,depthandsiteofburn,andavailabilityoflocaland internationalresources shouldbeconsidered inadditionto TBSAestimation.Suchfactorsarelikelytobedeterminedonly oncethepatienthasundergonedefinitivetriage.
Table2–Onscene:thefollowingcategoriesarerecommendedforburninjurytriage.
Triage category
Estimated TBSA(%)
Additionalcomments
Green(P3) <20
Yellow(P2) 20 40 Circumferentiallimbburnsandspecialareaburnscanbeconsideredhere.
Red(P1) >40 SymptomaticinhalationalinjuriesmustbecategorisedasRED.Circumferentialchest
wallburnsirrespectiveofTBSA%shouldbecategorisedasRED
Thedecision toassign apatient tothe ‘non-survivable’ triage category is a difficult and sensitive one within all cultures and communities, but more so in some contexts others.Supportforsuchdecision-makingisrecommended andcanbeofferedbytheBRRT.Onceadecisionhasbeenmade bythetreatinghealthcareteam,implementationofpalliative careinterventionsareessentialtoensurethepatient’sdignity andcomfort.Considerationshouldalsobegiventotheneeds ofthepatient’sfamily.
Patientswithnon-survivableinjuriesshouldbenursedat thehealthfacilitytheyhavebeeninitiallyreceivedin.However this decision should be at the discretion of the treating cliniciansandmaybeinfluencedbyavailabilityofnursingcare andlocalityofpatientfamily.
Recommendation5
OnScene: the tool first responders and / or healthcare workers are most familiar with should be used to determined TBSA.However ifnoneexist,theRuleofNinesTBSAestimationtoolforadults andthemodifiedRuleofNinesforchildrenshouldbeused.
TheTBSAestimationtoolutilisedonsceneshouldreflect thetoolmostfamiliartothefirstresponder.Thisislikelyto reduceerrorandsupportaneasytouseassessmentforfirst responderstodetermineTBSA.
Eachoftheburnestimationtoolshavetheirownmerits, andvariationinaccuracyisaccountabletoexpertise,experi- ence and patient body type [31,32]. On arrival atthe first receivinghealthfacility,additionaltoolsandburnexperienced healthcareworkersmaybeavailabletore-estimateTBSAas partoftheoverallre-assessmentandtriageofthepatient.
If guidance is indicated, use of the Rule of Nines is recommended.This method is simple, applicable across a varietyofcontextsandisacommonlyusedburnestimation toolusedinpre-hospitalenvironments[32].
Modern technology (for example mobile ‘Apps’) has greatly increased the options available to clinicians and strengthened accuracyofTBSAassessment[32]. However, resourcesenablingthe useofsuchdevicesarelikelytobe verylimitedinlowandmiddle-incomecountriesparticularly during the early phases of response. Many of the mobile technology applications supporting burn assessment are targetedtohigh-incomecountriesandtheresourcesavail- ablewithinthese.
It should be noted that across all contexts paediatric burnsareroutinelydifficulttoassess.A2017retrospective study of 123 paediatric burns patientsdemonstrated that approximately40% ofcasesreceivedaninitialoverestima- tion of TBSA by the early referring hospital. The study concluded that significant differences were observed be- tweentheTBSAassessmentofreferringhospitalsandthat madebyaspecialistburnsunit.Thisdiscrepancyimpacted ontransferdecisionstospecialistfacilities[31].Regularre- assessment and re-triage supported by burns expertise is thusrecommended.
Recommendation6
Triageshouldbeadynamicprocessrepeatedataminimumof three stages following a MCI involving burns. Additional
factorsimpactingsurvivabilityandTBSAestimationshouldbe consideredduring‘Arrival’and‘Definitive’triage.
3stagetriagerecommendations:
& On-Scene
& On-Arrival(atfirstreceivinghospital)
& Definitive(afterscrub/woundcleaningbyexperienced
burnshealthcareworkers)
Triageassessmentforburninjuriesshouldbedynamicand sequential.Athree-phasedapproachisrecommendedtohelp guidehealth-careworkersinpatientassessmentanddecision- making.
‘Arrival’and‘Definitive’triageareprocessesthatcanbe supportedbyaBRRTincollaboration withlocalhealthcare workers.
A three-phased triageapproach is important inpart to ensure accurate patient assessment following an evolving injury, but also to ensure patients are provided the most suitableinterventionsfortheirburninjuryinatimelymanner.
Thethree-phasetriageapproachalsohelpstargetnationaland internationalresourcestoneeds-forexamplehigheracuity burn care resources (e.g. specialist beds; intensive care capability)canbeappropriatelyallocated.
‘On-arrival’anddefinitivetriage
‘On-arrival’and‘definitive’triageshouldincludeassessment ofburndepthand confirmsiteofburn. Othersurvivability factors (e.g.patient ageand co-morbidities) shouldalsobe consideredduringthesephasesoftriage.Decisionsregarding onwardclinicalcareandre-distributionofpatientscanthenbe consideredonceamoreaccuratepatientassessmenthasbeen completed.
Part 2: Fluid management
Unliketraumainjuriesresultinginmassivehaemorrhageand where early ‘fluid’* (*in recent years packed red cells and clottingagentsratherthansalineorequivalent)isrequiredto preserve life,thefluidshiftsresulting fromburninjuriesis somewhatslower thus givingtimeforappropriatedelayed fluidmanagement.
Fluid replacement therapy in the management ofburn casualtiespromotedextensivediscussionwithintheTWGB, andsurveyresponders.Thereisclearevidencedemonstrating theneedforintravenousfluidsaspartofthemanagementof the systemic inflammatory response and capillary leak syndromefollowingasevereburninjury,withcomplications suchasacuterenalfailuresecondarytoburnsinjuriesbeing partlypreventablewithearlyadministrationoffluids[33 35].
However,broadevidencealsoexistsdetailingthecomplica- tionsofexcessivefluidadministrationinpatientswithburn injuries[36 38].Reportedcomplicationsincludeabdominal compartment syndrome, pulmonary oedema, interstitial tissueleakageandairwaycompromiseamongstothers.Fluid creep is a well recognised term used for excessive fluid resuscitationinthefirst24hafteraburninjury.Itincreasesthe chancesofdevelopingmanyofthecomplicationslistedabove [36,37,39,40].
InaccurateTBSAassessmentismostlikelytooccurinthe earlyresponsephase,andtheresultantfluidformulabasedon thisassessmentcanbeextremelydetrimentaltothepatient [41].Inahigh-incomemulti-centrestudyin2007,theauthors observedthatforevery5Lincreaseinfluidreceivedbythe patient, the risk of developing pneumonia, bloodstream infection, multi-organ failure and death was significantly increased[33].
Recommendation7
Onscene:intheeventofaMCI,oralfluidshouldbeencouraged (asappropriate) on-scene.Burninjuredpatientsshouldnot routinelyreceiveintravenousburnresuscitationfluidatthe scene.
TWGBexpertsreflectedontheirownextensiveexperiences frommanaging multiple burnspatients (a recent example being drawn from the Senegalese burn speciality team respondingtotheoiltankercrashinDemocraticRepublicof Congo[12])andconcludedthatintravenousfluidreplacement therapyforburnsvictimsshouldnotbedeliveredonscenebut once further clinical assessment of the patient has been undertakenatthefirstreceivinghospital.Anumberofpoints werehighlighted:
Therearelikelytobemultiple,competingdemandsforfirst responderstimeonsceneofaMCI.Theaccuracyof administrationofintravenousfluidmayeasilybeover- looked(forexampleensuringanappropriatevolumeof fluidistitratedviaadrip)andtheattentiontodetaillacking.
Theriskofadministeringaninappropriatevolumeof intravenousfluidtoapatientisthushighandtheresultant fluidrelatedcomplicationsincreased.Thiswouldbe particularlyhazardousinthepre-hospitalenvironmentto allpatientsbutparticularlythosesustaininginhalational injuries.
Ifextendeddelaysintransportingthepatientfromthe scenetoahealthfacilityarelikelyhoweverfluidsmaybe considered,includingjudiciousintravenousfluidsusing theformulassuggestedinRecommendation8aincasesof
>40%TBSA.Therisksoffluidcreepandothercomplica- tionsfromoverresuscitationbyintravenousfluidmustbe consideredandmitigatedfor,especiallyasaconsequence ofanoverestimatedTBSA.
Inpatientswithconcurrenttraumainjuries,onscene intravenousfluidsshouldbeconsideredonacase-by-case basisasperstandardtraumaprotocolsaccordingtotypeof injury,injuryseverityandtheclinicalstatusofthepatient.
Concernswereraisedinthesurveyfromthewiderburn communityregardingtheriskoforganhypo-perfusionand subsequentcomplicationswhenon-sceneintravenous fluidsarenotgiven.Theseconcernsarejustified.However, fieldexperiencesfollowingmasscasualtyburnincidents havesupportedtheTWGBconsensusthaton-scenefluid resuscitationforburninjuryisnotonlyimpracticalinthis setting,butthatitsindividualandcollectiverisk/benefit ratioislikelytobeunfavourable[42].Thisismostlydueto thelossofefficiencybroughtbyimplementingany complexinterventionon-scene,tothedifficultyofman- agingpotentialcomplicationsofoverlyactivefluid
resuscitation,andtothehighprobabilityofsuchover resuscitationrelatedtoaforementionedinaccuracyofon- sceneTBSAassessment.
Logisticallythesheervolumeandweightofintravenousfluid thatwouldneedtobetransportedbyfirstrespondersor broughttosceneifintravenousfluidswereinstigatedduring thisphaseishighlyimpractical.Ifintravenousfluidis providedper‘normalregime’(suchasmodifiedParkland Formula,2mL/kg/%TBSAinthefirst8h)inthepre-hospital phase to 50 patients with an average 40% TBSA and an average 70kgbodyweight,theestimatedoverallweightoftrans- portingtheestimatedfluidvolumeisaround280kgfor8h.
Recommendation8a
At the first receiving hospital: The following initial fluid regimesarerecommended:(Table3).
Followingextensivediscussionsandreviewofliterature theTWGBconcludedthataspecific,simple,practicaland effective fluid formula should be recommended for this particularcontextandcohortofpatients-i.e.wherethere are multiple burninjuredpatientsfor whomtimelyburn care management and where resources are likely to be stretched.
Oralfluids
Therapeutic efficacy with theuseofenteral fluids inthe managementofsevereburnswasfirstdocumentedbyFox in1944[43].Chilledisotonic1.75%sodiumlactatesolution wasadministeredenterally(10 15%ofbodyweightinfirst 24 hours), and subsequently adjusted in its volume to maintain a urine outputof1 2 litres daily.A numberof adultandpaediatricpatientswithextensivefullthickness burnsreceivedtheoraltherapywithgoodeffect[43].Inthe 1960s,Sorensonsoughtasimpleandeffectivewaytotreat mass casualtiesfrom thermal nuclearwarfare. Over a16 month periodall patientsadmitted to aburns unitwere permitted todrink ‘adlibitum’, aimingforapproximately 15%ofbodyweightper24hourstobedrunk..Foreachlitre consumed,a5gsalttabletwasalsogiven.Sorensonfound that 80%ofpatientswith burnsnot exceeding 45%TBSA
Table3–TWGBrecommendfluidregime:Atthefirst receivinghospital:thefollowinginitialfluidregimesare recommended.
%TBSA Fluidrecommended
<20% Oralfluidstothirst.Nointravenousfluids
recommended
20 40% SupportwithOralRehydrationSolutionas soonasispracticableatavolumeof100mls/
kg/24hConsiderIVfluidasappropriate*
*Considertheneedformorefluidsinchildren
<15kg
>40% 100mls/kg/24hintravenouscrystalloidsand
drinkasable
*Considertheneedformorefluidsinchildren
<15kg
drankadequatelyandrequirednoadditionalfluidtherapy
for‘anti-shock’treatment[44].
Subsequent studies exploring the efficiency of enteral fluids(intheformofORS)ratherthanintravenousfluidsasan effective approach to fluid management of burn injured patients have been undertaken [45,46]. Observations from thesestudieshighlightedtheimportanceofconsideringthe useofenteralfluidsasasuitablealternativetointravenous fluidsuptoacertainTBSAburn.
The TWGB recommend that, when able, oral fluids be started on-scene withburninjuredpatients encouraged to drinktothirst.Oralfluidcanbeprovidedaspotabledrinking water supplemented with Oral Rehydration Salts. This approachtopatientfluidmanagementshouldbecontinued beyondarrivalatthefirstreceivinghospitalandguidedbythe patient’sclinicalresponse.Ifintravenousfluidsareindicated, oralsupplementationcancontinue.
Intravenousfluid
Thereareanumberofrecognisedguidelinesandformulaefor fluidmanagementinburnscare,primarilyfocusedoncareof theindividualburnspatient[47 50].Littleevidencehowever existsdetailingtheimpactofminimalfluidadministrationin theearlyphaseofresponsetoaburncasualtyandwhetherthis wouldcauseharmorbeofbenefitespeciallyintheeventofa MCI.A2017reviewidentifiedthatduetothe challengesof austereenvironmentsfluid resuscitationcanbedelayedor restrictedinburnsup to40%TBSA providedthe patientis quicklytransportedtoatreatmentfacility[51].Thecompli- cations of aggressive fluid resuscitation however are well documented [36,37,39,40]. In addition to clinical complica- tions, logistical considerations should also be taken into account.
The recommendation detailed above suggests, when indicated,intravenouscrystalloids(lactatedRinger,supple- mentedwithdextroseinchildren)shouldbegivenatavolume andrateof100mls/kg/24h(TBSA>40%).Burnedsurfacearea (%TBSA)howeverformsnopartofthecalculationunlikein otherburnfluidformulae.Thissupportsamoresimplifiedyet fullyindividualisedapproachwherebyfluidvolumeadminis- tered should be routinely adjusted in accordance with patient’s clinical response and not adhered to in a strict formulaicmanner.
Ifapatientneedsahighvolumeoffluidduetodeteriorating clinicalcourse,earlyadvancedairwayinterventionshouldbe consideredinconjunctionwiththeincreasedresourceneed foron-goingpatientcare.
Recommendation8b
The recommended administered fluid regime should be calculatedfromtimeofarrival atthe firstreceivinghealth facilityandnotthetimeofburn.Fluidstatusofthepatient should be assessed regularly (urine output; capillary refill time;heartrate;respiratoryrate)andfluidregimeadjusted accordingly.
Inaccordancewithamorejudiciousoverallapproachto intravenousfluidtherapyforburnspatientsinthecontext described,theTWGBrecommendthatthevolumeofintrave- nousfluidadministeredtopatientsshouldnotincludeany
‘catch up’ fluid. This approach to intravenous fluid management may help mitigate the risks of fluid over resuscitation and enables moreaccurate recording offluid volumegiven.
The patient’s clinical response to intravenous and oral fluids isthe mostimportantdeterminantofpatientfluid / hydrationstatusinaMCIandcanhelpdictateon-goingfluid estimates. Goal directed fluid therapy has been a long recognisedimportantconcept influidresuscitation ofburn patientsparticularlyintheinitialphase[48,52 54].However invasivemonitoringtohelpmeasureresponsetofluid(suchas cardiacoutputmonitoring)isnotlikelytobeavailablewithin manycontexts,norbeasuitabletooltobeutilisedaspartofa masscasualtyresponse.
Part 3: Immediate first aid and dressings
Recommendation9Potable/drinking watercanbeusedtocool andclean burn wounds.
Recommendation10a
On scene: the following management of burn wounds is recommended:
Coolburnwoundiflessthan3hsinceinjurywith(running) potablewaterifavailable(avoidhypothermia).
Ifavailable,providepainrelieftopatient.
Removedebris/irritantfromthewoundandcleanas thoroughlyaspossiblewithpotable/drinkingwater.
Coverburnwithalightcleandressingorplasticwrap(non- circumferential).
Avoidnonevidencedbasedpracticessuchasapplying eggs,butter,toothpasteorsimilarontheburn.
Recommendations10b
Atfirstreceivinghospital:onarrivalthefollowingburnwound careisrecommended:
Coolburnwoundiflessthan3hsinceinjurywith(running) potable/drinkingwaterifavailable(avoidhypothermia).
Provideanalgesiatopatient.
Re-triagepatient(on-arrivaltriage).
Cleanwound/scrub.
Re-estimateTBSA.
Determineburndepth.
Confirmsiteofburn.
Re-assessforotherinjuriesincludinginhalationalinjury.
Re-triageafterwoundclean/scrub(definitivetriage).
Confirmtetanusstatus(andgiveboosterand/orImmu- noglobulinifindicated).
Determineappropriatedressing.
Atthefirstreceivinghospital:recommendationsfor:
theearlymanagementofinhalationalinjuryinclude:
Sitpatientupifnosuspicionofothertraumainjuries(i.e.
burninjuriesonly);
Avoidexcessfluid;
Considerearlyintubationandventilation.
Patientswith<20%TBSAandno‘specialarea’burns
Considerearlydischargewithout-patientfollowupif<20%
TBSAandsuperficial/partialthicknessornon-specialarea burns.
Ensureadequateout-patientsupportforthosedischarged (e.g.woundcare,socialandcommunitysupportandclear carepathwaycommunicated).
Patientswith>20%TBSAand/ordeepdermalor‘special area’burns
Patientsshouldbereviewedbyanexperiencedburn clinician.
Suchpatientsarelikelytobenefitfromon-goingin-patient care.
EnsurecomprehensivedocumentationofTBSAestima- tion,burndepthandburnsiteinadditiontostandard clinicalhistoryandexamination.
Patientswithburnsin‘specialareas’suchasacross/near joints,hands,faceorfeet,andthosewithlargeburnsto benefitfromgraftingandsubsequentscarmanagement, shouldbereviewedbyarehabilitationspecialist.
Immediatefirstaidforburninjuryinfluencestheclinical courseandseverityoftheburn[52,53,55].Basicfirstaidshould include cooling, pain relief, cleaning and application of a simplecleandressingtotheburnwound.Coolingoftheburn woundshouldoccurup tothreehoursaftertheinjurywas sustainedandthuscanbecontinuedfromsceneintothefirst receivinghospital.Evidencehasdemonstratedbenefitinburn care,andareductioninfuturecomplications,frombothgood effectivebasicfirstaiddeliveredbyfirstrespondersandinthe coolingofaburnwithinthis3hourtimeperiod[56 61].
First aid treatment should continue fromscene to first receivinghealthfacility.
Recommendation10c
Following aburns MCI,antibioticsshould notroutinely be givenprophylactically toburns patients unless specifically clinicallyindicated(e.g.compoundfracture)[62].
Dressings
Theeffectiveness,practicalityandcostofdressingsmustbe takenintoaccountwhenevaluatingwhatwouldbethemost suitable for aburn MCI. There is, however, little available evidenceon anyoftheseconsiderations.Onerecent paper estimatingthecostimpactofdressingchoiceinthecontextof amassburncasualtyeventdidfindincreasedcostsassociated withtheuse ofsilverdressings.Importantly howevertime savingswerealsoidentified-savingsthatmighthelpoptimise burns management by minimising the time nurses spent doingdressingchanges[63].
There arenowanumberofdressingsavailable thatare designedtobeleftinplaceforalongerdurationthanthemore traditional daily or alternate day dressings. However, the formerareconsiderablymoreexpensive.
Twooptionsfordressingsshouldbeconsidered:
Thetraditionaldressingsusedroutinelyatthehealth facility;and/or
themorespecialistdressingslikelytobeexternally sourced.
Recommendation11
Thereisnooverwhelmingevidenceofonetypeofdressing over another,therefore the TWGB donot recommendany superior dressing regime. Dressing type should be chosen accordingto:
Thewoundcharacteristics(e.g.infectedversusnon- infected;donorsite).
Pointofapplication(on-sceneorhealthfacility).
Availabilityofdressings.
Cost-benefitimplicationsandresourcerequirements(e.g.
staffing);andabilityofpatienttoreturnforfollowup.
InaMCI,availabilityofstafftoregularlychangedressings anddressingavailability(potentiallyaffectedbylackoflocal and international re-supply) are likely to be compromised.
Considerationalsoneedstobegiventothelogisticalrequire- mentoftransportingdressingsifbroughttothefacilitybya BRRT(i.e.packagingweightandvolume;airtransportcosts;
clinicalwastedisposalrequirements,andlocaltransportation).
Silver impregnated dressings,as opposed tosilver oint- ment,areoftenusedtohelppreventinfectionandpromote healing.Howeverevidenceoftheirclinicalandcosteffective- nessremains controversial[64].Inlow andmiddle-income countries,accesstosilverbaseddressingsandavailabilityof funding tosupporttheir useis likelytoberestricted.This limitationwillbemagnifiedintheeventofahighnumberof patientsreceivingburncareatanyonetime.
Various anti-septic agents have been used for burns management including povidine-iodine, alcohol, chlorhexi- dine, and honey as wellas more non-evidenced practices [65,66].Silverhoweverhasremainedoneofthemostpopular duetoitsperceivedbenefits.
Dressing type and duration may need to be adjusted dependingonthetypeandcharacterofthewounddressed (e.g.donorsitewound;infectedburn)andstaffavailability.
Part 4: Surgical interventions
Recommendation12Surgicalinterventioncapacityforthecareofburnspatientsat thefirstreceivinghospitalshouldincludeescharotomyand scrub provided the facilities, infrastructure (e.g. operating theatre)andlocalskillsetisavailable.Additionalexpertisevia aBRRTand/orBSTcansupporttheseproceduresinadditionto furtherinterventionsasindicated.
Surgicalcareshouldbeimplementedatthefirstreceiving hospital.Proceduresthelocalsurgicalteamareunfamiliaror inexperienced inshould be supportedby clinical expertise fromaBRRTand,ifrequired,aBST,inadditiontotheprovision anduseofwrittenproceduralguidanceandchecklists.
Proceduresthatmaybeperformedbynon-burnsurgeons includewoundcleanandscrub,escharotomyandfasciotomy.
Excision and grafting procedures must be performed by surgeonsskilledinburnscareand/orbysurgeonssupported byclinicalexpertise[67].
If early excision and grafting is undertaken at the first receivinghospital,thepatient’scareshouldcontinueatthat facilityandnotransferofthepatientundertakenunlessclinical coursedeteriorates.Asalifesavingintervention,escharoto- miesand/orfasciotomiesweredeemedtobeanimportantpart oftheinitialmanagementandstabilisationapproachtoburn patientsarrivingatthefirstreceivinghospital[68 70].
TBSAestimation,depthassessmentandburnsiteconfir- mation should be revised following scrub to help guide definitivetriageandaiddecisionmakingregardingtransfer.
Patientswith>20%TBSAafterscruband/or‘specialareaburns’ arerecommendedforreferralandtransfertoamorespecialist facility.Patientswith<20%TBSAwithon-goingsurgicalcare, andthosewithsuperficial‘specialarea’burnsshouldremainat thefirstreceivinghealth facility.This supportsrationingof resources by ensuring capacity of specialist hospitals is preservedforthemorecomplexandextensiveburns[71].
Earlyandlateburnscare
Aspartofstrategiesforburnscare,thedefinitionofearlyversus lateburnsmanagementwasalsoconsideredwithagreement withinthe TWGBthat fullthicknessburnsshould ideally be managed within the first week (early excision) and partial thicknessburnsbeyondweekone(lateexcision)topermithealing ofthoseareasthatmighthealwithdressingsalone[48,72 76].
FollowingdiscussionswithintheTWGB,itwasconsidered appropriate for a local surgical team in a non-specialist hospital(e.g.district)toperformscrubandexcisiononTBSA estimatedupto20%inadultsand10%inchildren.However,a stagedapproach tothis interventionisadvisedand,where possible,supportedbyburnexpertise.Skilledburnsurgeons (supportingadistrictortertiaryhospital)wouldberequiredto undertakeexcisioninpatientswith>20%TBSA(adult)and
>10%TBSA(children)[77].
Paediatric burns>10%TBSA (determined afterdefinitive triage); inhalational;and specificchemicalburns shouldbe triagedtoandmanagedinatertiaryhospitalwhenpossible[71].
Earlyrehabilitationforallpatientswithburninjurieswith supportfromrehabilitationspecialistsshouldbeencouraged [78].Rehabilitationspecialistsarepotentiallyalsowellsuited to take over the care of burns patients once surgical interventionandwoundcarehasbeencompleted.
Part 5: Rehabilitation
Recommendation13Whenindicated,rehabilitation-includingactiveandpassive exercisesandfunctionalretraining-shouldcommenceatthe
earliestphaseofcare,oncevitalfunctionsarestableandwith precuations considered. Precautions to consider include relatedtrauma,woundbreakdown/graftfrailty,k-wires,low bloodpressure,orinfection.
Early access to rehabilitation can have a significant impactonpatientoutcomesandreducetheriskofsecondary complications,suchasimmobilityandcontractures[79,80].
Inthecontextofburnsinjury,thefocusofrehabilitationis on:
Minimisingtheimpactofscarringonrangeofmovement;
Reducingdisfigurement;and Supportingfunctionalrecovery.
Rehabilitationspecialistshavespecificskillstotargetthese objectives. However,improvingpatientoutcome fromburn injurythrougheffectiverehabilitationstrategiesremainsthe responsibilityoftheentiretreatingteamincollaborationwith thepatient[81].
Rehabilitationrecommendationsshouldbeconsideredfor allpatients(basedonburnseverityandlocationofburn)on theirarrivalatthefirstreceivinghospital[78,80,82].Depend- ingonneed,rehabilitationinterventionsmayinclude:
Scarmanagement;
Respiratoryphysiotherapy;
Anti-contracturepositioning;
Rangeofmovementexercises;
Splinting;
Stretching;
Ambulation;
Strengthandcoordinationexercises;and Activityofdailyliving/functionalretraining.
Scar maturation can continue for 12 18 months and complications canarise foryears followingdischarge from acutecare[83,84].Thusidentificationandcoordinationwith localrehabilitationprovidersanddisabilityorganizationsisan importantaspectofdischargeplanningparticularlyinaMCI.
This is especially critical for paediatric patients who will benefitfromon-goinginterventionduetotheimpactofgrowth onscartissue.
Adequate analgesia should be administered prior to rehabilitationinterventionsaspaincanreduceparticipation andperformance.Earlymobilisationisencouraged,including aspartofpatientself-care.
Activeandpassiveexercisesandfunctionalretraining:
Thehyper-metabolicresponsefromsevereburns,coupled withprolongedbed-rest,makepatientsvulnerabletodecon- ditioningandsecondarycomplications[48,85].Rehabilitation supports the cardiorespiratory system, reduces oedema, reducestheriskofpressureareasandcontractures,aswell asreadyingthepatientfordischarge[79].Thisisespecially critical in the context of limited inpatient bed availability characteristicofMCI[86].
Recommendation14
Whenburnsaregrafted(deeppartialorfullthicknes:)position theburnt/graftedskinsoastocounteractcontractileforces,
using splints when indicated, to prevent contracture and manageoedema.
Splintingcanbeusedafterskingraftingtoimmobilisethe limb. The typical regime after skin graft is to continually immobilizetheaffected jointarea(s)forfivetosevendays, followedby night-wear ofsplints. However this should be decided in consultation with the surgeon. Splints may be appliedintheatrewhilstthepatientisunderanaesthesiaor duringpost-operativerecoverytominimisediscomfort.The indicationforsplintingisbasedontheseverityandlocationof theburn, andthe patient’sabilitytomoveactively[48,80].
Splintingshouldbeparticularlyconsideredforyoungchildren and sedated patients who may not be able to actively participate in stretching and exercises. Photographs or picturescanbeusedtoillustrateidealpositioning.
Splinting and anti-contracture positioning should be consideredforconservativelymanagedwoundsthatdonot healwithintwoweeksastheriskofscarringincreasesinthese incidences.Thermoplasticistheidealsplintingmaterialasit canberemouldedovertimeandcanachievegoodconformity but alternativematerials, suchasPlaster ofParisand PVC piping, may also be considered in more resource-limited settings[87].Innovativeresourcescanalsobeusedformouth andnecksplints.
Burn contractures can develop rapidly (within weeks).
Splintingandpositioningareessentialformaintainingtissue lengthduringwoundhealingand tomaximisefunctioning [48]. Oedema after burn injury can be aggravated by limb dependencyandcanrestrictwoundhealingandmovement,as well as exacerbate pain. Elevated positioning facilitates lymphaticdrainageand,alongwithmassageandcompres- sion,canbeusedtoeffectivelymanageoedema.
Recommendation15
Compressiontherapyandmassageshouldbeusedtomini- mizescarringandmanageoedema.
Compression can be achieved with bandaging, tubular elasticstockings,andpressuregarments.Whilecustomised compression garments may not be available in resource- limitedsettings,compressionshouldaimtoachieveapressure of24mmHg[83].Compressionbandagesorgarmentsshould be worn 23 h a day, with regular monitoring, until scar maturation[83].Aspatientswithsevereburnswillcontinueto usecompressionandmassagewellbeyonddischarge,educa- tionincorrectuse/techniqueiscriticalinadditiontoeducation about on-going scarcare. Encouragingparticipation during inpatientstayimproveschancesofcontinuityafterdischarge.
Inthecontextofmoderateandsevereburns,compression therapycanreducescarheightandcanalleviatesomeofthe discomfortofimmaturescars,suchasbloodrushanditching.
Scarmassagesimilarlyworkstosoftenscarsandcanimprove skinmovementandreducehypersensitivity[48,85].
Recommendation16
Where an inhalationinjury is suspected, early advice and respiratorycareshouldbecommenced.
Respiratory complications from inhalation injuries will affecteachpatientdifferently.Earlyrespiratoryrehabilitation
and optimal early patient positioning can help alleviate symptoms andprevent future complicationsinadditionto ensuringthepatientisequippedtomanagetheirsymptomson discharge[82].Wherepossible,earlymobilisationshouldbe encouraged to enable the patient to clear secretions and maintaincardiorespiratorysystemfunction[79].Forchildren this maytakethe formofplay. Aprogrammeofbreathing exercisesandmanualtechniquesshouldbeusedtosupport thepatienttomaximiselungfunctionandchestexpansion [79].
Part 6: Burn teams
TheroleofBurnRapidResponseTeamsandBurnSpecialist Teamsaredistinctbutcomplimentary.
BurnRapidResponseTeams(BRRTs)
BRRTsshouldplayapivotalroleintheearlyphaseofresponse to a burns MCI to support the localhealth system. Often nationalorregionalteams,andlikelytobefamiliarwithlocal context,themainrolesofaBRRTcanbecategorisedinto:
Assessing Clinical Co-ordination
Assessing:
Earlyassessmentofthecurrentsituationwithestimatesof patientnumbers.
Provisionofacomprehensivecheckonresourceavail- abilityinthefirstreceivinghealthfacilityandspecialist burnfacilitiesiffeasible.
Clinical:
Supporttolocalhealthcareworkerswiththeclinical assessment,re-triageandon-goingcareofpatientsatthe firstreceivinghealthfacility.
Supportandguidancetolocalhealthcareworkers,once triageandrelevanttransferhasoccurred,inthedeliveryof surgicalinterventionsforburncare(e.g.earlydebridement andgrafting).
Supportthecareofpatientsreceivingpalliativecare.
Co-ordination:
Ifrequested,supporttolocalco-ordinatingteamsin hospitalsandcentrally.
Partofthedecision-makingteamregardingpatient transferandpatientre-distribution.
AssistingtheH-EOCtodeterminetheneedforadditional expertiseintheformofBSTs.
Oncerequested,nationalBRRTteamsshouldideallydeploy immediately (within 6 12 h) followinga request from the affected localhealth authority. BRRTs are notexpected to assiston-sceneandarebestplacedfocusingtheirsupporton
thefirstnon-specialistreceivinghospitals.Thismechanism also helps preserve the country’s local and national burn expertiseattheirrelevantspecialisthospitals(thoseindividu- alswhoarenotpartoftheBRRT).
BRRTsshould ideallytobe self-sufficient,carryingtheir own specialised equipment, consumables, communication tools,food,waterandhabitat(i.e.selfsufficientfortheirown needsandinordertoperformtheirfunction)foraminimumof 3daystoundertakecoreactivitiesaroundtriageandpatient distribution.Ifcircumstancespermit,BRRTscanstayonlonger toassistwithdirectclinicalcare.
Burns MCIs are unlikely to have damaged all local infrastructure, thus large caches of tents and logistical equipment arenot required, rather teams should be light andportabletofacilitaterapiddeployment.Self-sufficiencyin termsoffood,waterandhabitatforteamscanbethroughthe useoflocalaccommodationifthesearenotaffectedbythe incident.Theteamsshouldexpecttobeself-sufficientinterms ofpayingfortheirownlocalbillsorhavethiscoveredthrough their deploying agency and not be a burden on the local system.
The development of BRRTs is encouraged within all countriesandguidancefortrainingand evolutionofteams willbeprovidedaspartoftheEMTtoolkit.
Shouldacountryhavefewburnsspecialists,orpreferto retaintheseatthenationalreferralcentres,thenBRRTsmaybe soughtfromsurroundingcountries.Theseteamswouldneed to comply with international EMT standards and be self- sufficient/self-caringforuptotwoweeks.,InternationalBRRTs shouldbeawaretheywilllikelybedeployedintoahospital lackingmuchofaburnsserviceandthusincludewithintheir kitburncareequipmentandconsumablestoperformtheir task.
Recommendation17a
RecommendedcompositionofBurnRapid ResponseTeams (BRRT):(Table4).
TheBRRTisrecommendedtobeanationalteamwith capabilitytodeployquicklyandefficientlytosupporta numberofroles.
BRRTsarenotrecommendedtoattendthesceneofthe incidentbutprovidetheirexpertiseatthefirstreceiving healthfacilities.
BurnSpecialistTeams(BST)
BSTs are larger teams comprised of a multidisciplinary healthcareworkerswithextensiveburnexperience.Whether
nationally or internationally based teams, BST’s have a numberofimportantroles:
Supporttheon-goingclinicalcareofburnpatients.
Provideadditionalexperiencedpersonneltoprovide support,adviceandguidancetolocalhealthcareteams.
Supportsurgecapacityinburnscareandactasa‘force- multiplier’bybolsteringthecapacityoflocalhealth facilitiesinmanagingburninjuries.
Provideexpertiseparticularlyregardingrehabilitationand long-termtreatmentplansforpatients.
BSTsareexpectedtodeployfollowinginvitationfromthe localhealthauthorityorH-EOCafterinitialassessmentbythe BRRTs.InternationalBSTsarenotlikelytoarriveincountryfor severaldaysaftertheinitialincidentbutshouldremainfora minimumof6weeks.
InlinewithBRRTsandtheminimumstandardsandcore principles for EMTS, BSTs must be self sufficient for a minimumof2weekspriortore-supply.BRRTsandBSTsare notexpectedtoprovidetheirownfieldinfrastructureasteams aremostlikelytobeco-locatedwithanexistingfacility.
All countriesshouldconsider creatingaBRRTorhaving bilateral or regional agreements to request BRRTs from neighbours aspart oftheirnationalEMT systemand their nationalemergencyresponseplan.BSTsarepotentiallyless likelytobedeployed,moredifficulttoputtogether(especially for long deployments) and may be best shared regionally amongmultiple countries-eithersourced fromonelarger country,and/orwithcontributionsofexpertsandresources fromnearbycountrieswithintheregion.
Much ofthe discussionwithinthe TWGBregardingBST capacityrevolvedaroundthespecificplacementofexpertise.
The main role of a BST has been recognised as capacity buildingparticularlyforanexistinghealthfacility.Itmaybe preferabletokeepnationalhealthcarestaffandexpertisein theirexistingplaceofworkwherefamiliarityresidesrather thanre-distributepersonneltosupportotherfacilities arole that could be supported by a BST. Resource allocation is recommended to be determined on a case-by-case basis dependentonlocalcontextandresources,BSTavailabilityand typeofincident.
Recommendation17b
RecommendedcompositionofBurnSpecialistTeams (BST):
(Table5)
AlongwithBRRT,BSTsshouldberegisteredbylocal authoritiestoworkforatime-limitedperiodintheaffected
Table4–RecommendedcompositionofBurnRapidResponseTeams(BRRT).
Numberperteam Skillrequirement
TeamLeader 1 e.g.emergencyresponsemanagerexperience(thisisanonclinicalrole) Burnsspecialistsurgeon 1 Minimum5yearsexperienceinburnscareacrossvariouscontexts;
BurnsexperiencedAnaesthetist 1 Minimum5yearsexperienceinburnscareacrossvariouscontexts;
Burnsexperiencednurse 1 Minimum5yearsexperienceinburnscareacrossvariouscontexts
Logistician 1 WithWASHandwastemanagementexperience
countryandbetaskedbytheH-EOC,toworkinsupportof relevantfacilitiesandlocalhealthteams.
MinimumrecommendeddeploymentofaBSTis6weeks giventhecomplexityofburnscareandlonginpatientstays.
Staffmayberotatedwithinspecialtyteams(asispractised withinotherformsofEMTs),butideallythiswouldbe infrequent,andcarefulhandoverwouldbeindicated. BSTsshouldsupportstrategiestoensuresmoothhandover
ofpatientswithon-goingcareandfollow-up.
BSTsarerecommendedtohelpprovidetrainingand mentorshiptolocalspecialists.
BSTsandBRRTsshouldensureweeklyactivitiesare reportedtorelevantauthoritiesthroughouttheirdeploy- mentandafinalexitreport.
Part 7: Training
Recommendation18AllBRRTandBSTpersonnelshouldhavecompletedgeneric EMTtrainingandsafetyandsecuritytraining(eitheraspartof anEMTtrainingorseparately)priortobeingeligibletojoina burns team. In particular, all members should complete trainingfocusingonadaptationofclinicalcareaccordingto context-including inresource-limitedsettings -andteam focused training. Successful completion of this training is recommendedasapre-requisiteforselectiontoaBRRTorBST.
Additional specific training for BRRTs and BSTsshould include:
Assessment,co-ordinationandleadershipinMCIswith burninjuries.
Clinicalcareincludingresuscitationandsafeburnpatient transfer.
Decisionmakingregardingthemanagementofmultiple burnpatients.
Localandnationalco-ordinationmechanismsandpatient transfers.
Surgecapacitymanagement.
‘LessonLearnt’fromburnMCIs.
The target audience for burns specialist training are practising clinicians and members of local co-ordination systems(forexamplepersonnelfromtheH-EOC).
Recommendation19
Allburnsteampersonnelshouldcompletespecialisedtraining inburnscarespecificallyfocusingonMCI,whilstteamleaders andcliniciansshouldalsohavetrainingincoordinationand emergencymanagement.
Globally, utilisation should bemade ofexisting courses which meet the expected learning outcomes, ensuring trainingisregionallyaccessible,openaccessandeconomically viable.
Personnelwiththerelevantburnsandtrainingexperience are encouraged to provide a mentorship role to emerging teamsandsupportdeliveryoftrainingasexpertfaculty.
Trainingshouldencompassablendedmodularapproachto learningandknowledgeacquisition(forexampleworkshop- based activities, immersive simulation, classroom based sessions). Considerationshouldalsobegiventosupporting community education programmes around on scene first responder burn care. Training for teams in low resource contexts should be sensitive and responsive to local and culturalneeds,relevanttothetypeofhealthcareprofessional workingwithburnspatientsandtailoredtomeetthebasic, intermediateandadvancedlevelsofburncare[2,7].
TheWHOEMTToolkitwillprovideanopenaccessvirtual platform for supporting curriculum material and training guidance.
GuidanceonEMTtrainingcurriculum,contentanddelivery canbeaccessedviathevirtualEMTToolkit.
Guidanceonastandardisedmasscasualtyburnresponse curriculum,coursecontentanddeliveryofspecifictraining willbeavailableviathevirtualEMTtoolkit.
Table5–RecommendedcompositionofBurnSpecialistTeams(BST).
SkillSet Essentialexperience/CoreSkills Number
perteam
Desirableexperience
TeamLeader Experienceworkinginhealthemergencyresponseco-ordina- tion(thisisanonclinicalrole)
1 Experienceindisastermanagement
Burnsspecialist surgeons
>5yearsburnsexperiencewithgeneraltraumaexperience 2 Experienceworkingintraumamass
burnsormasscasualtyacrossvarious contexts
Anaesthetist Withburnsexperience(>5years)andICUexperience 2 Experienceortraininginvariouscontexts Nurses Withburnsexperiencepaediatricexperience(2 5years).
Nursesshouldhaveexperienceinburnsdressings,autoclaving, operatingtheatrenursingand1 2withclinicalleadership experience
5 Burnstraining,ifpossibleacrossvarious contexts
Medicallogistician Formanagementofconsumablesandpharmacy 1 Experienceinemergencyhealthdeploy- ments,managingmedicalstocketc.spe- cificforburnscare
Generallogistician 1 Experienceinemergencydeployments
includingmanagingteamselfsufficiency, aswellasabilitytosupportpower,water Rehabilitation
specialist
With>3yearsburnsexperienceincludingsplintingand
respiratorycare
2
TrainingforBRRTsisrecommendedtobedeliveredata nationallevel.
TrainingspecificforBSTscanbedeliveredcentrallyata regionallevel.
Part 8: Infrastructure and self-sufficiency
Recommendation20AllBRRTsandBSTsareexpectedtobeself-sufficientfortheir ownneedsandfortheequipmentandconsumablesrequired forthe surgical and burnscare capacity theywill provide.
Howevernationalteamsmaybepartiallysupplied bylocal hospitalsthroughapre-establishedcollaborativeagreement.
Inaccordancewithrecommendationsinthe‘BlueBook’, BRRTs and BSTs are expected to be self-sufficient for a minimumof3daysfornationalteamsandaminimumof2 weeksforinternationalteams[1].However,teamsarelikelyto co-locatewithanexistingfacilityandthusarenotrequiredto deploywiththeirownfieldinfrastructureoraccommodation tents..
Recommendationsregardingtheequipmentteamsshould deploywillbemadeavailableintheEMTToolkit.Following initialsituationalassessmentbyincomingBRRTs,anyaddi- tionalresourcescanbesourcedandprovidedbytaskedBSTs.
Considerationshouldalsobegiventothetaskingofother specialistEMTssuchasthosesupportinglogistics(i.e.logistics specialistteam).Theneedforsuchteamscanbedetermined by BRRTs once assessment of the situation and resources availablehasbeencompleted.
SurgeResponseCapability
BRRTsandBSTsshouldsupportefficientandtimelyscalingup (anddown)ofresources tohelpensureresources areused appropriatelyandwithoptimalimpactacrosshealthfacilities managingthepatientinfluxandongoingcare.Strengthening surgeresponsecapabilitybenefitsfromcollaboration,cohe- sivenessandclearcommunicationamongstallinvolvedandis animportantroleforbothtypesofteam.
Equipment
Amodularisedapproach toequipment isrecommended.A modularsystemsuchasthatdetailedbelowhelpssupportsa standardisedandsimplifiedframeworkforburnsequipment andexpeditere-supply(Table6).
1. InfrastructureModule
Burnsteamsareexpectedtoco-locatewithanexistingfacility and,althoughself-sufficiencyofburnsteamsisrequired,they arenotexpectedtobeself-sufficientinthesamemanneras EMTs1 3.MCIsresultinginburninjuriesare,ingeneral,not likelytodamagehealthfacilityinfrastructureonalargescale (e.g.oiltankerexplosion).However,thereareexceptionsto thisandconsiderationshouldbegiventoself-sufficiencyin suchincidences.Theseinclude:
Conflictresultinginthermalandnon-thermal(e.g.
chemical)burnstoalargepopulation.Infrastructural
damagemayexistduetoconflict,especiallyifhealth facilitiesarespecificallytargeted.
Explosionwithinahealthfacility.Surroundinghealth facilitiesmayhowevernotbeimpactedand,withexternal support,abletoprovidetheburnscareneededandwhere burnsteamscanco-locate.
Gasplumesorotherformsofcontamination(e.g.radiation) maymakeitunsafetousenearbyhealthfacilitiesand temporaryEMTfacilitiesmayhavetobeerectedinanother saferarea.
AburnMCIasaconsequenceofasuddenonsetdisaster.
LocalandregionalfunctioninghealthfacilitiesandEMTs (nationalandinternational)willprovideaninfrastructural platformfordeliveryofhealthcare.BRRTandBSTscanco- locatewitheither.
Guidance onthe recommendedequipment burnsteams shouldcarryforinfrastructuralsupportincludingequipment neededforoperatingtheatreinfrastructurewillbeavailableon the EMT Toolkit.Equipmentrequirementscan beadjusted accordingtoidentifiedneedsfollowinginitialassessmentby BRRTs, andshouldbetargetedtosupportlargescaleburns responseandreplenishmentofdepletedlocalburnresources.
Additionalinfrastructuralsupport,forexampleintheform of aspecialist logistical team witha wardmodule, canbe requestedbyBRRTsshouldthisbeidentifiedasaneed.
2. Laboratorymodule
Burnteamsshouldaimtoaugmentthelaboratoryequipment available locally. Information on the receiving hospitals existinglaboratorycapabilityshouldbedeterminedbyBRRTs and equipmenttoaugmentlaboratory capabilitycommuni- catedtoBSTspriortotheirarrivalincountry.
Standard questions regarding the availability of blood transfusionservices,basiclab,autoclaveandradiology(CXR inparticular)arerequiredandifnotpresentteamsshould bring.
3. Pharmacymodule
Quantityisestimatedbasedonatwo-weekre-supplyandthus in line with recommendations for EMTs inthe Blue Book.
Adjustmentscanbemadetoquantityanditemsaccordingto localneeds.Logisticalmeasuresshouldbeinplaceamongst burnsteamsforensuringcoldchaintransportandstorageif required.
Table6–Recommendedequipmentmodules.
OperatingTheatreInfrastructure andConsumablesModule LaboratoryModule PharmacyModule BloodGivingModule SurgicalModule RehabilitationModule DressingModule Resuscitationmodule