Emergency nurses care for 30 badly burned patients in one night
Emergency nurses care for 30 badly burned patients in one night
Their interventions had direct impact on survival
Imagine treating 30 severely burned patients in a single night. That was what ED nurses faced at Memorial University Medical Center in Savannah, GA, after an explosion at a local sugar plant.
Twenty of the injuries were severe enough to be transferred to a burn center, and of these, 17 were intubated in Memorial's ED, all at the same time.
"I was in charge the night of the explosion. This was my first mass casualty," says David Bramble, RN, senior staff nurse in the emergency department. "The intensity of that night cannot be measured. To see my team come together and work so hard, with so much determination and with so much heart, was inspiring."
The 17 critical patients had burns to the face, chest, back, arms, and neck, and all required rapid assessment and treatment, he says. "Most of the burns were greater than 50% of their body surface mass," Bramble reports. "Nurses assisted in endotracheal intubation, intravenous access, sedation and pain management, burn care, and thermal regulation of the patient's body temperature."
The severely burned patients faced an uncertain prognosis after they left the ED, adds Bramble. "In reality, these patients have a very long and hard road ahead of them, if they survive initially," he says. Of the 20 patients transferred from the ED, five have been discharged, and five died.
The care in the ED has a direct impact on the patient's survival, says Laura L. Cox, RN, BSN, clinical burn educator at the Joseph M. Still Burn Center in Augusta, GA, which received the 20 critical burn patients from Memorial's ED. "If a burn patient does not have a patent airway, we would not have a burn patient to treat," she says. "If the burn patient does not get fluid resuscitated, they will go into hypovolemic shock due to the decrease in circulating volume."
You can never be too prepared
The biggest lesson learned by ED nurses after this event was that "you can never be prepared enough," says Bramble. "There can never be too much training, classes, inservices, or drills," he points out.
John L. Dekle III, RN, BSN, clinical director of the ED, credits the nurses' quick response to their participation in countywide disaster drills. "You can never practice enough of those," he says.
ED nurses participate in burn inservices offered throughout the year, held at Memorial or at the Burn Center in Augusta, and some have taken Advanced Burn Life Support (ABLS), Advanced Cardiac Life Support (ACLS), and the Trauma Nursing Core Course (TNCC) offered through the Emergency Nurses Association. "All of the advanced training we did helped us with the basics of airway, breathing, and circulation," says Bramble. "The night of the explosion required us to draw from our training, knowledge, and experience."
Memorial's ED nurses were "put to the test" that night, recalls Bramble. "The ED, the hospital, and all our team members passed the test with flying colors, showing we do have the capacity, knowledge, and training to handle a mass casualty," he says.
Initially, nurses were informed they could be getting up to 200 patients, says Dekle. "We really had no idea what we were getting into. The first thing we did was make sure we had plenty of fluids in the department," he says. Nurses obtained dressings, gauze, pain medications, sterile sheets, and extra stretchers and wheelchairs to transport patients.
At the time of the initial report, there were about 60 patients in the ED, so beds had to be made available for the incoming patients. Patients were discharged if possible, or moved out of the acute care area to another part of the ED, which opened up 21 acute care beds.
Although St. Joseph's Hospital in Savannah was prepared to accept six high-acuity critical patients, none were taken there, but emergency nurses took immediate action to prepare for the anticipated arrival of numerous critical burn and blast patients. Karen Hust, RN-CEN, MSN, BSN, AND, advanced clinical educator for the ED at St. Joseph's, says, "The disaster plan was put into effect, with an overwhelming response from our staff and outside resources. Nonetheless, we did not receive any patients until late in the evening, and these few presented by private vehicle for minor injuries."
Nearly 100% of nurses reported to the ED and quickly reviewed the disaster protocol including the triage process, assignment to rooms, registration and identification, and briefly reviewed initial burn care with the trauma teams. Next, ED nurses obtained intravenous (IV) lines and dressing supplies, placed ventilators in each of the designated trauma rooms, and hung bags of normal saline and Ringer's lactate to begin immediate fluid resuscitation, says Hust.
"Each trauma team was assigned an ED room and proceeded to prepare that room for their patient," says Hust. "Equipment was sent from all areas of the hospital, including IV pumps and poles, stretchers, and ventilators."
Many of St. Joseph's ED nurses recently had completed the TNCC. "The nurses were glad to have had this course while preparing for the influx of patients that was expected by this disaster," says Hust.
To improve care of burn patients at your facility, do the following:
• Make airway, breathing and circulation (ABCs) your first priority.
The best thing that the Savannah ED nurses did for the burn patients is to "treat them as any other patient," says Cox. "They worried about the ABCs first before anything else, and then about fluid resuscitation," she says.
When it comes to emergent burn care, many people are taken aback by the appearance of a burn patient, Cox says. "Go back to your ABCs," she says.
Assess the need for immediate intubation, prior to swelling and occlusion of the airway, advises Hust. Also determine whether circumferential injuries are noted, says Cox. "If so, check pulses every 15 minutes and elevate extremities," she says. "Provide 100% humidified oxygen by nonrebreather. Intubate if there is possible inhalation involvement or facial burns."
• Stop the burning process.
Remove all clothing and jewelry to decrease the time of contact, says Cox. "This can possibly prevent a partial thickness burn from becoming a full thickness burn," she says.
• Do not apply topical antimicrobials if the patient is being transported to a burn center.
"This will obscure the visualization of the wound bed, and it is important that the receiving facility be able to visualize the burns," says Hust.
If your patient has less than 10% of their total body surface area burned, cover the burned area with normal saline-moistened gauze, but if it's over 10%, cover the burns with dry gauze, says Hust.
• Calculate the total body surface area burned to determine appropriate fluid resuscitation.
Give the patient between 2 ml and 4 ml of fluid multiplied by their weight in kilograms, multiplied by their total body surface area burned, says Cox. Give half of the calculated amount of fluid in the first eight hours post-injury, with the rest of the fluid given in the next 16 hours, she says.
"Monitor urine output for 30-50 cc per hour for an adult," advises Cox. "If you are not getting adequate output, increase your fluid by a third."
For more information on care of severely injured burn patients in the ED, contact:
- David Bramble, RN, Emergency Department, Memorial University Medical Center, Savannah, GA. Phone: (912) 350-8113. E-mail: [email protected].
- Laura L. Cox, RN, BSN, Clinical Burn Educator, Joseph M. Still Burn Center, Augusta, GA. Phone: (706) 651-2282. E-mail: [email protected].
- John L. Dekle III, RN, BSN, Clinical Director, Emergency Department, Memorial University Medical Center, Savannah, GA. Phone: (912) 350-8271. E-mail: [email protected].
- Karen Hust, RN-CEN, MSN, BSN, AND, Advanced Clinical Educator, Emergency Department, St. Joseph's/Candler Hospital, Savannah, GA. Phone: (912) 658-6779. Fax: (912) 691-9224. E-mail: [email protected].
The Advanced Burn Life Support (ABLS) Provider Course is an eight-hour class covering assessment and management of the burn patient during the first 24 hours post-injury. The course includes lectures, case studies, and opportunity to work with a simulated burn patient. For a course schedule, go to the American Burn Association's web site (www.ameriburn.org). Click on "ABLS Advanced Burn Life Support Courses Learn More" and then "ABLS Course Schedule." To register for an online course available for $175, on the home page, under "Meeting and Course Information," click on "ABLS Now Course Available Online," and scroll down to "Registration." For more information, contact the ABA/ABLS, Chicago. Phone: (312) 642-9260. Fax: (312) 642-9130. E-mail: [email protected].Imagine treating 30 severely burned patients in a single night. That was what ED nurses faced at Memorial University Medical Center in Savannah, GA, after an explosion at a local sugar plant.
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