Principles and Practice of Burn Care

Organization of a Burn Unit
38
Madhuri Gore
Chapter
INTRODUCTION
Optimal functioning of a burn unit demands commitment
from the burn team and the hospital administration. A
specialized burn unit can contribute significantly to the field
of burn care as it offers following advantages—
1. Facilitates accrual of experience.
2. Permits implementation and evaluation of protocols.
3. Facilitates collection and analysis of data.
4. Provides stimulus for innovation and research.
5. Provides facility for training.
6. Opportunity to improve the quality of burn care leading
to reduction in mortality and morbidity.
The main purpose of a burn unit is to minimise the
incidence of infection in burnt patients and to provide
comprehensive burn care. The design of a burn unit should
be conducive for this purpose. A typical burn unit should
have provision for 11-18 patients.1 The actual number of
beds depends on the available data about patient load.
MEMBERS OF BURN TEAM
The core of the burn team is formed by:
1. Unit Director - Burn surgeon – General or plastic surgeon
with one year fellowship in burn care and at least 2
years experience.2 Junior consultant surgeon and training
surgeons complete the surgical contingent.
2. Nurse Manager – with at least two years experience in
acute burn care and 6 months of managerial experience.2
Nursing staff and trainee nurses complete the nursing
team.
3. Microbiologist
4. Nutritionist
5. Physical and occupational therapists, respiratory
therapists.
6. Clinical psychologist
7. Social worker.
8. Labor staff.
The specialists from following departments should be
available for consultation:
General Surgery, Orthopedics, Cardiothoracic Surgery,
Otorhinolaryngology, Neurosurgery, Urology, Ophthal-
mology, Obstetrics/Gynecology, Internal Medicine,
Pulmonary Medicine, Anesthesiology, Radiology, Pediatrics,
Nephrology, Psychiatry, Neurology, Cardiology, Pathology,
Gastroenterology, Microbiology, Hematology.
CASUALTY
The patient receiving area may be a part of the burn unit or
of the Accident and Emergency department of the hospital.
It should be easily accessible and should have an identified
attending medical professional available 24 hours.
Facility size: A 12 feet × 12 feet area is comfortable for
accommodating patient trolley, personnel and equipment.
Equipment: Intensive care patient trolley, crash cart with
life saving equipments and drugs are essential components
of the receiving area.
Weighing facility should be available.
Central suction and oxygen supply is desirable. A suction
machine and oxygen cylinder with regulator and humidifier
may be an acceptable alternative.
The instrument sets for the following procedures should
be available:

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Principles and Practice of Burn Care
1. Intravenous access including venesections and blood
collection for investigations.
2. Tracheostomy.
3. Escharotomy/Fasciotomy
4. Insertion of nasogastric tube
5. Perurethral catheterization.
A dressing trolley with dressing materials in adequate
quantity should be available if the receiving area is a part of
burn unit. If it is in Accident and Emergency Department,
the patient can be wrapped in a sterile drape and transported
to the burn unit for further wound management.
The following documents should be displayed or be
readily available in the receiving area:
1. Burn unit admission criteria
2. Protocol for initial evaluation and management.
3. Chart for evaluation of extent of burn.
4. I/V access protocol
5. Contact telephone numbers.
6. Burn mass casualty action plan.
DESIGN OF BURN UNIT
By definition, burn unit is a part of a multispecialty hospital
and should occupy either a complete floor or a part of it.
Control of infection should be the basic consideration while
deciding the distribution of space in a burn unit. In order to
minimize the transportation of micro-organisms, the
necessity for movement of health care workers, patients
and waste material within the unit should be reduced. This
can be achieved by:
•
Allocating zones within the unit for each category of
patient condition (acute, infected, high dependency, non-
acute / convalescent) and equipping each zone with all
the patient-care requirements for daily routine (therapy,
hygiene, staff areas, etc.). Depending on the available
space, convalescent care area may be located outside
but in physical proximity of the acute and high
dependency care area of burn unit
•
Keeping immunosuppressed, infected and acute patients
isolated in single rooms;
•
Employing appropriate measures for environmental
control
•
Organizing unidirectional traffic routes and corridors
so that during routine procedures there are no points of
contact between the various zones.
A concentric design with central nucleus of patient
support and general service area; intermediate band of patient
care rooms; external visitors’ corridor has been
recommended.1
The service areas should include:
•
A nurses’ station
•
A kitchenette / pantry
•
An on-call restroom
•
Staff changing room
•
Stores
•
An examination room for out-patients
•
An operating suite, including a “clean” operating theater
and a dressing room
•
A conference/meeting room and a communication room
are desirable if the space permits.
The patient care rooms can be of different designs
depending on the type of patient. The number of beds in
each category will depend on the average number of
admissions (The numbers indicated here are considered
appropriate for about 400 admissions per year).
a. The patient at high immunological risk (acute and
infected): 4 + 4 = 8 beds
b. The patient without particular immunological problems
and in non-acute but high dependency state, i.e. after
complete resuscitation, between wound excision and
closure procedures: 8 beds
c. The patient in convalescent phase with healing of more
than 50 % of the burnt area till the time of discharge: 8
beds
Acute Care Area
For acute or septic patients a single room is considered
essential. Ideally, to limit still further the patient’s transfer
and the consequent dispersal of organisms, each room should
have an adjoining:
•
WC with sluice disposal (separate for each room)
•
Hydrotherapy room (one between two single rooms,
accessed through an air-lock from each side)
•
Filter/ante-room (separate for each room, positioned
between bedroom and access corridor and acting as
air-lock to the tub room) would be ideal.
The minimum desirable dimensions of the acute care
room are 10 ft × 10 ft × 10 ft The room should have central
oxygen supply and central suction facility. The equipments
needed for providing acute intensive care are as follows:
1. Intensive care bed – 1
2. A set of resuscitation equipment including laryngoscope,
endotracheal tubes, Ambu bag, connections, suction
cannulae, emergency drugs.
3. Multipara monitor / capnometer / cardioscope with pulse
oxymeter (depending on availability of funds) - 1
4. Syringe infusion pump – preferably 2, at least 1.

Organization of a Burn Unit
539
5. Nebuliser – 1
6. Dressing trolley with dressing drum.
7. Stand-by suction machine.
8. Patient care articles such as bedpan, kidney tray, etc.
9. Hand disinfection facility should be provided in the ante-
room or in the patient room in the absence of ante-
room.
The acute care area should have
1. Sophisticated ventilators—Ideally 8 (one for each ICU
bed), but at least 2, along with the required accessories.
2. Intensive care trolleys—2.
3. Crash cart—1.
4. ECG machine—1.
5. Portable X-ray machine—1.
6. Multipara monitor in each room connected to central
monitoring station at nurses’ station and closed circuit
television facility in each room for observing the patient
from nurses’ station would be an asset that can be
procured at a significant cost.
7. Vacuum cleaner – Heavy duty—1.
Surgical residents: 2 surgical residents should be assigned
to this area.
Nurse: Patient ratio: 1: 1 very desirable for all shifts.
A dressing assistant is necessary for morning shift.
Helper staff of minimum 4 ward attendants and 4 cleaners
is necessary for every shift.
High Dependency Area
A room with two beds is desirable, with WC and shower
for each room. At least 5 feet should be available on either
side of the patient bed for ease of procedures and infection
control. The equipment that should be available for each
bed is:
1. Intensive care bed.
2. Central suction and oxygen facility.
3. A set of patient care articles.
4. Dressing trolley with dressing drum.
5. Splints, extremity supports.
Each room should have:
1. Pulse oxymeter – 1
2. Nebuliser – 1
3. Wheel chair – 1
4. Syringe infusion pump – 1
5. Volumetric infusion pump for constant rate nasojejunal
tube feeds.
6. Simple physical therapy equipments.
7. Hand disinfection facility.
The high dependency area should have
1. Sophisticated ventilators – 2;
2. Intensive care trolleys – 2;
3. Crash cart – 1;
4. Physical therapy equipments;
5. Vacuum cleaner – Heavy duty – 1;
6. Washing machine – 1;
Surgical Residents: At least 1 surgical resident should be
assigned to this area.
Nurse: Patient ratio: 1:2 for morning shift and 1:3 for other
two shifts with patient allocation. A dressing assistant is
necessary for morning shift. Helper staff of minimum 3
ward attendants and 2 cleaners is necessary for every shift.
The Convalescent Care Area
The convalescent care area should be in the proximity of
ICU and HDU. It should have at least 8 beds. This can be a
big hall with adequate space between the beds with facility
to isolate the patient with curtains. Each bed should be
provided with central suction and oxygen facility. Windows
and exhaust fans can be used for providing good natural
ventilation. At least 4 showers and WCs should be provided
in the toilet block of the ward. Indian WC is unsuitable for
burnt patients as squatting can be extremely difficult. Every
bed should have a set of patient care articles such as chair,
bucket, mug, and bedpan. Separate dressing drum for each
bed is highly desirable and separate dressing trolley should
be definitely considered. Use of patient cabinets should be
avoided as these act as breeding areas for pests and insects.
Instead a shelf can be provided for each bed for keeping
personal articles of the patient. Hand disinfection facility
should be provided for each bed.
This area should have service areas such as nurses’
station, changing room, pantry, store, dressing room,
physiotherapy and recreation area. The following equipments
should be available in this area:
1. Patient trolleys – 2
2. Wheel chairs – 2
3. Crash cart – 1.
4. Nebuliser – 1.
5. Suction apparatus – 1.
6. Physical therapy equipment.
7. Vacuum cleaner – 1.
8. Music system
9. Television
10. Pulse Oxymeter – 1 – desirable
11. Syringe infusion pump – 1 desirable

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Principles and Practice of Burn Care
Surgical Residents: At least 1 surgical resident should be
assigned to this area.
Nurse: Patient Ratio: During morning shift when maximum
patient care activities are carried out, at least 2 qualified
nurses should be available along with one dressing assistant.
In other two shifts at least 1 qualified nurse should be posted.
A dressing assistant is necessary for morning shift.
Helper staff of minimum 2 ward attendants and 2 cleaners
is necessary for every shift.
ENVIRONMENT CONTROL
The purpose of environmental control measures is:
1. To reduce the load of bacteria carrying particles
2. To impede the passage of air from areas with lower
grades of asepsis (e.g. service areas) to those where
the level of sterility is required to be high (e.g. patient
room, dressing room) by maintaining pressure gradient.
3. To provide comfortable environmental temperature so as
to help control the hypermetabolic state of the burn
patients by reducing shivering.
4. To provide optimal humidity so as to control evaporative
losses and to aid wound healing process.
5. To dilute the smells while keeping noise to minimum.
Air changes: Appropriately designed air treatment plant
would serve this purpose by maintaining different levels of
asepsis in the air according to the function of the space.
The reduction of bacterial content in the air can be brought
about by either filtration or sterilization. High efficiency
particulate air (HEPA) filters have the smallest pore size,
but its use entails high recurring expenditure. Filters with
3-5 micron size pores are considered adequate for ICU.
The sterilization is effected using ultraviolet lamps positioned
either directly in the room or in the air conditioning ducts as
a complement to the filters.1
Three systems of high-efficiency cleansing are:
1. laminar flow
2. directed vertical flow
3. Joubert system.
Laminar flow systems exist with either horizontal or
vertical orientation. In both cases the air-flow acts on the
entire air volume and is characterized by its very high air-
change rate (300-540 volumes/hour).
Directed vertical flow concentrates its action on the area
in which the medical team is operating and in proximity of
the patient. The system’s capacity (20-25 changes/hour,
which can drop to 15 when rooms are not in use), although
notably lower than that of the laminar flow, is seen to reduce
the content of Colony Forming Units (CFU) per cubic metre
to a suitable level for delicate operations.
The Joubert system is a system based on directed vertical
flow for operating rooms, introducing certain modifications:
the air change rate is of around 50 volumes/hour; of these,
6 vol/H are fresh external air, while the other 44 are recycled
from the room and filtered.1 In the author’s experience
directed vertical flow system with 20-24 fresh air changes/
hour reduces the CFU/cubic meter to less than 10 which is
considered adequate. Regular maintenance of the system
needs to be carried out by cleaning/changing of filters,
cleaning of ducts and microbiological surveillance.
Temperature: Environmental temperature equal to normal
body temperature i.e. 35°C is optimal for controlling the
metabolic rate and to prevent shivering of burnt patients.
This is most often perceived uncomfortable by the health
care professionals as it causes sweating, fluid loss and easy
fatigue. In the author’s experience temperature of about
30°C is an acceptable compromise for both patient and staff
if maintaining different temperatures in the patient rooms
and service areas is not possible due to resource crunch.
Humidity: Humidity of 55-60 % is desirable.
Use of air curtains at identified entrances helps to maintain
pressure gradient and thus aids control of the microclimatic
conditions.
CONSTRUCTIONAL CONSIDERATIONS
The material used for floor and walls of the burn unit should
be chosen with a thought about infection control, ease of
cleaning and durability. The cost of the material could be a
major deciding factor in presence of resource crunch.
The floor: Floor needs to withstand heavy load and traffic.
It should be dust resistant, non slippery and easy to clean.
Epoxy coating satisfies these criteria, but is expensive.
Amongst the natural stones, marble is unsuitable as its high
porosity supports trapping of moisture and growth of
organisms. Granite is slippery and expensive. Polished Kota
or polished Shahabad is strong, durable, affordable, easy to
clean and with least porosity. Use of large size slabs would
reduce the number of joints.
The walls: The walls should be covered from floor to ceiling
with suitable material which should be dust resistant, non
porous, easy to clean. Large, marbo-granite tiles are

Organization of a Burn Unit
541
considered suitable as the porosity is less than ceramic tiles
and the surface is dust resistant.
The ceiling: If false ceiling is planned, it should be of
aluminium panels for ease of cleaning. If the ceiling needs
painting, plastic emulsion or oil paint is recommended as
both are moisture and dust resistant and easy to clean.
Cleaning: Use of vacuum cleaner is strongly recommended
for cleaning of floor, walls and ceilings of all the areas in
the burn unit. This sucks and removes the dust while
sweeping displaces it.
The windows: If open ventilation is being used in the unit,
the windows must have nets to prevent entrance of flies,
mosquitoes and other insects. A strict protocol for cleaning
of nets needs to be prepared and implemented.
OPERATION THEATER
The operation theater can be a part of the burn unit or it
may be an identified OT in the surgical OT block which
would save space and personnel.
1. Size – 20 feet × 20 feet
2. Operation table with facility to suspend extremities with
the help of detachable rods or rails suspended from
ceiling.
3. All usual OT equipment such as anesthesia machine,
central gas supply and suction facility, cautery machine.
4. Thermal blanket, patient warmer, on-line fluid warmer,
multipara monitor.
5. Air changes – 20-25 fresh air changes/hour, Temperature
– 35° C, Humidity – 55-60 %.
6. Surgical team should have 2 surgeons, 2 assistant
surgeons and 2 nurse assistants.
7. Special instruments – Skin grafting knife of choice.
Dermatome is an asset, adequate number of blades, Skin
graft mesher, dermacarriers.
DRESSING ROOM
During a dressing procedure, the bacterial density in the
dressing room increases significantly. 8-10 air changes are
needed to reduce the density to acceptable level. This would
need a time gap of 30 minutes between two dressing
procedures. In a busy burn unit it is impractical to follow
this discipline. The author is convinced that doing dressings
in the patient’s own room is a convenient alternative. Selected
dressings may be done in the dressing room with adequate
time interval between the procedures. The dressing room
should be of 12 × 12 feet for ease of manipulation of patient
trolley. The environment control specifications would be
same as for OT. It should have adequate supply of sterile
dressing equipments and agents. A weighing machine can
be conveniently placed in the dressing room for ease of
implementing daily weight protocol.
HYDROTHERAPY FACILITY
A large number of burn units outside India use Hubbard
tank for hydrotherapy. In author’s opinion this is unsuitable
for burn units in India for several reasons
1. The time taken for each patient is about an hour.
Considering the number of patients in India, this would
mean having multiple tanks which entails significant
expenditure.
2. In the absence of appropriate cleaning of the tank, the
risk of endogenous as well as cross infection is certainly
increased. With constant paucity of trained and
committed personnel, this is a definite possibility.
The experience in India as well as abroad suggests that
shower bath (with hand held – telephone shower) using
appropriately modified patient trolley is an effective
alternative.3 In contrast to the Hubbard tank, the trauma
table was observed to have the following associated
advantages: (1) quicker treatment sessions; (2) less pain to
the patient; (3) elimination of patient exposure to
contaminated water; (4) more comfort for the therapist;
and (5) greater ease in patient handling, for example, rolling
the patient onto a stretcher or bringing the patient into a
sitting position. The use of the sterilized disposable plastic
sheet was observed to be the most effective procedure to
decrease the risk of contamination between patients during
the shower.4 The hydrotherapy facility should have adequate
space and wide enough doors for manipulation of the trolley.
Hot and cold water mixer with telephone shower attachment
and appropriate drainage provision is necessary, inexpensive
and easy to use and maintain. In ICU and HDU, trolley lined
by sterile plastic drape is appropriate while in convalescent
care area the patients may walk or be taken on a wheel
chair for hydrotherapy.
It is important to note that hydrotherapy may not be
safe for patients with hypovolemia, sepsis and hypothermia.
For such patients it is advisable to perform sponging of
non-burnt body parts and wound cleaning and dressing on
the patient bed.

542
Principles and Practice of Burn Care
Provision must be made for appropriate collection and
disposal of waste generated in the hydrotherapy area without
contaminating the patient care areas. Maintaining this
unidirectional movement is crucial for infection control and
needs to be incorporated in the unit design.
PHYSIOTHERAPY UNIT
Physical therapist should visit the unit twice a day for passive
and assisted and supervised exercises for every patient. For
patients in ICU, splints and extremity supports should be
available for optimal positioning. The extremity supports
can be prepared from thermoplastic material or aluminium
sheet (cheaper). Extremity supports designed at the author’s
unit cost about Rs. 200 /- for foot support and Rs. 400/-
for upper extremity support. These have been observed to
be effective and are easy to disinfect. Readily available
aluminium splints for wrist and hand, elbow, ankle and knee
help in providing splinting and are easy to disinfect.
The physiotherapy equipments that should be available
in HDU and convalescent care area are
1. Cycle pedals fixed on a stand
2. Pulleys for upper extremity exercises.
3. CPM (Chronic Passive Motion) machines for different
joint movements should be available, whenever needed.
4. Parallel bars can be provided in the unit if the space
permits. The walker should be available.
5. Simple games such as peg in the hole, building blocks
provide valuable exercise for fingers and wrists.
6. Toy cars and cycles provide excellent therapy to pediatric
patients while they play.
7. In author’s observation, group exercise therapy
improves patient participation significantly. This can be
effectively conducted in convalescent care area and for
select patients in HDU.
It is necessary to ensure regular cleaning and disinfection
of all the equipments. Besides the physical therapist, the
nursing staff and surgical team should encourage the patients
to perform activities of daily routine along with the exercises.
The physical therapists also have to provide respiratory
therapy not only to the patients with inhalation injury but to
all the patients in the unit. The necessary equipment (nebulizer,
incentive spirometer) should be available in the unit and
disinfection of the mouth pieces between patients should
be ensured.
MONITORS
The details of desirable equipments in different areas of a
burn unit have been provided earlier. The number and type
of monitors would vary depending on the available resources.
It is important to recognize the need to be vigilant and to
use available monitors judiciously. The brain behind the eyes
that look at the monitor screen is the most important
equipment.
The possibility of outsourcing monitors and ventilators
should be explored and a plan to do so should be ready and
known to all involved.
Upkeep and maintenance of monitors, ventilators and
infusion pumps needs to be done regularly to ensure optimal
functional status.
UTILIZATION AND COST CONTAINMENT
Establishment of a burn unit is an expensive proposition. It
should not be undertaken if optimum and appropriate
utilization is not ensured. In our country, if a burn unit has
to be closed for lack of patients, it would call for a
celebration. But resource crunch is a major issue that plagues
most of the burn units. To combat this problem we must
find our own solutions based on sound scientific principles.
The burn team should discuss various shortfalls openly and
the team leader must encourage suggestions from each and
every member. Imaginative innovations and their critical
evaluation would certainly lead to development of methods
that would take us ahead on the path of progress. The
measures suggested here for environment control are
expensive and available funds may not be sufficient. It should
be realized that these are not solutions in isolation to the
problem of hospital infections. These infections are the result
of interacting causes, none of which should be undervalued
or ignored and should be countered using interacting
measures. For these reasons surgical and nutritional
treatment and, above all, the conscientious respect of hygiene
discipline on the part of all members of staff are of
fundamental importance and cannot be substituted by any
of the expensive gadgets. Large, well ventilated, multi-bed
burn units can also generate impressive results with strict
attention to cleaning protocols and barrier nursing. Excellent
nutritional support can be provided using locally available
inexpensive items of food instead of commercially available
tube feeds or nutritional supplements. Paucity of funds
should be considered as an opportunity to innovate. Burn
care requires a high staff-to-patient ratio and a hospital budget
to support this is mandatory. The author strongly feels that
the resource crunch should not compromise the number of
health care professionals in the burn unit –especially the
nursing staff. Such a step is extremely detrimental to the
quality of care and may result in loss of several valuable

Organization of a Burn Unit
543
lives. This causes irreparable damage to the morale of
existing staff, leading to further deterioration of services.
ACTIVITIES OF BURN UNIT
The burn unit should not be satisfied just with provision of
burn care. The responsibility of the burn team and the unit
extends much beyond to encompass the following.2
Performance Improvement Program
The burn unit should have a performance improvement
program that is multidisciplinary.The burn unit
multidisciplinary committee, which oversees the
performance improvement program, should meet at least
quarterly. Sufficient documentation should be maintained
to verify problems, identify opportunities for improvement,
take corrective actions and resolve problems.
Morbidity and mortality conferences should be held at
least monthly with physicians other than the immediate burn
care team to ensure objective review of the presentations.
Attendees at this conference must include specialist staff
members other than those practicing in the burn unit. All
significant burn complications and all deaths must be
discussed. There must be open, candid discussion with high
points documented and assessment of the death or
complication classified as “caused by disease,” “potentially
preventable,” “possibly preventable” (or the equivalent
thereof). Actions recommended must also be documented,
and there must be documentation of loop closure. Records
of this conference must be kept.
Patient care conferences shall be held at least weekly to
review and evaluate the status of each patient admitted to
the burn unit. Each clinical discipline should be represented
in order to appropriately contribute to the treatment plan
for each patient. Patient care conferences shall be
documented in the progress notes of each patient and/or in
minutes of the conference.
Audit
The burn service should conduct audits at least annually
that should include, but should not be limited to, the severity
of burn, mortality, incidence of complications and length of
hospitalization.
Educational Programs
The burn unit should have an educational program for the
medical and nursing staff.
If residents rotate on the burn service, the burn service
director or his or her designee should be responsible for an
orientation program for new residents.
Infection Control Program
The burn unit should have effective means of isolation that
are consistent with principles of universal precautions and
barrier techniques to decrease the risk of cross-infection
and cross-contamination.
The burn unit should provide ongoing review and analysis
of nosocomial infection data and risk factors that relate to
infection prevention and control for burn patients.
Continuity of Care Program
The burn unit must provide the following services:
1. Recreational therapy for children cared for in the unit
2. Education in rehabilitation
3. Support for family members or other significant persons
4. Coordinated discharge planning
5. Follow-up after hospital discharge
6. Access to community resources
7. Evaluation of the patient’s physical, psychological,
developmental and vocational status
8. Planning for future rehabilitative and reconstructive needs
Burn Prevention Program
The burn unit should participate regularly in public burn
awareness programs.
Research Program
The burn unit should participate in basic, clinical, or health
sciences research.
Allograft Skin Bank Program
The burn unit is responsible for smooth functioning of
allograft skin bank program including record of donors and
recipients and graft utilization.
FUNCTIONING OF BURN UNIT
A burn unit of above capacity needs 1 burn unit director
and minimum 2 burn surgeons besides 4 surgical residents
and nursing staff as indicated. The duty roster of burn
surgeons should be planned to ensure availability of one
surgeon at all 24 hours. One surgical resident should be in
the ICU area all the time and one more should be available in

544
Principles and Practice of Burn Care
the campus at any time. For management of mass casualty
situation, enrolment of all the surgical residents should be
planned.
The burn team consists of surgeons, nurses, helper staff
and therapists. Team work is the key to successful
functioning of a burn unit. Co-ordinated efforts are also
crucial for performing all the above activities. The burn
unit director with leadership qualities has to nurture the burn
team. The team members need guidance, direction and
encouragement for upgrading their performance.
Acknowledging the contribution of the team members,
encouraging them to discuss their views and problems,
providing psychological support during stressful periods,
helps in building a cohesive team that can achieve impressive
results even with scanty resources. Freedom to think and
express can lead to new developments. Participation in
training programs and scientific forums helps in boosting
up self esteem and desire to excel. Each member should
feel proud of being part of the burn team. This harmony
generates sustained self motivation which can produce
superior results.
Interaction Schedule
Besides daily interaction between the burn surgeon and the
patient, following is the suggested schedule of interaction
between the burn unit director and members of the burn
team and burn team and patients and their relatives.
Schedule of minimum frequency of patient care activities:
1. Wound inspection by burn surgeon – once daily
2. Communication between burn surgeon and relatives –
once daily
3. Nutrition compliance by nutritionist – once daily
4. Physiotherapy and respiratory therapy by physiotherapist–
twice a day
5. Splinting and positioning by occupational therapist – once
daily
6. Counseling session with clinical psychologist – twice
weekly
7. Session with social worker – once weekly
8. Interaction between nurse in-charge and relatives about
participation of relatives – once daily
9. Counseling by occupational therapist to all the patients
and relatives about scar management – twice weekly.
Schedule of interaction between director and burn team:
1. Director and nurse-in-charge – once weekly
2. Director and nutritionist, physical therapist, occupational
therapist – once weekly.
3. Director and patient’s relatives – once weekly minimum.
4. Director and microbiologist – once monthly.
5. Un-announced visit by the director to assess adherence
to burn unit protocol – once weekly
6. Un-announced visit to the burn unit by the microbiologist
to evaluate adherence to infection control protocol –
once weekly.
Funding
Burn care entails significant expenditure due to the need for
intensive care, prolonged hospital stay, multiple procedures,
expensive medications, long rehabilitation program and high
staff-to-patient ratio. Adequate budgetary provisions should
be made by the administration to meet the exigencies.
As Curreri5 said, the burn unit succeeds or fails on the
basis of managerial capability. Managers are responsible for
accumulating resources, educating personnel, maintaining
morale and integrating the burn unit with the rest of the
hospital. Moreover, it has become apparent that burn unit
managers must become financial managers as well, if we
are to: 1) maintain reasonable resources for the conduct of
research; 2) participate in a variety of health delivery
systems; 3) curtail health delivery costs; 4) maintain the
current excellence of clinical care in an efficient manner;
and 5) guarantee access of patients to the burn care delivery
system at a cost that the country can afford.
It is the responsibility of the Director of the burn unit to
garner funds needed for smooth functioning of burn unit
and for conducting different activities. Procurement and
maintenance of necessary equipment depends on the ability
of the director to convince the management of the hospital
and on the level of commitment of the management. In the
author’s experience, funding can be obtained from
philanthropic individuals, organizations and industry, for
research and educational programs as well as for equipments.
Besides the high quality of work; sincerity, commitment
and transparency in utilization of funds are excellent
advocates. The author truly believes that “If you have the
purpose, means will follow”.
SUMMARY
A burn unit is only as good as its staff.6 Trained experienced
nurses, therapists and surgeons accustomed to dealing with
large open wounds are a major requisite for the care of
burned patients who have a multisystem disease. The field
of burn care demands high level of commitment, consistent

Organization of a Burn Unit
545
excellent quality performance and ability to generate
enthusiasm sometimes in the face of all adversities.
Burn unit’s physical spaces and mechanical systems are
designed to reduce infection, promote patient comfort, and
improve staff efficiency and morale.7 Patient and staff are
the focal point of a burn unit and should continue to remain
so for encouraging outcome.
REFERENCES
1. Magliacani C, Teich Alasia S, Bormioli M, Stella M, Musci F, Holmes
J. Structural aspects in a burn unit: proposal of expanding models.
Dept. of Plastic Surgery and Burn Centre, Turin, Italy, Architects,
Annals of the MBC - vol. 5 - n’ I - March 1992.
2. Guidelines for the operation of burn units, Resources for optimal
care of the injured patient, Committee on Trauma, American College
of Surgeons Chapter 14:1999.
3. Neville C, Dimick AR. The trauma table as an alternative to the
Hubbard tank in burn care. Burn center, University of Alabama
Hospital, Birmingham 35233, J Burn Care Rehabil 1987 Nov-
Dec;8(6):574-5.
4. Akin S, Ozcan M. Using a plastic sheet to prevent the risk of
contamination of the burn wound during the shower. Burns. 2003
May; 29(3): 280-3.
5. American Burn Association Presidential Address 1984: Burn Unit
Success – a problem of management. Curreri PW, J Trauma 1985
Jan; 25 (1):1-10.
6. Snelling CF, Can J Surg. The comprehensive burn unit 1985 Nov;
28(6):478-81.
7. Young SR, Thilliander BD, Patients, staff are focal point of new
burn unit hospitals. 1980 Feb 16;54(4):93-9.

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Principles and Practice of Burn Care
Burn Injury Management in
Disasters: Indian Perspective
39
Ravindra Tah
Chapter
INTRODUCTION
Disasters: Definition and Impact
The Webster’s Dictionary defines a disaster as ‘a grave
occurrence having ruinous results’. The World Health
Organization (WHO) defines disaster as ‘any occurrence
that causes damage, economic destruction, loss of human
life and deterioration of health services on a scale sufficient
to warrant an extraordinary response from outside the
affected community or area’.
The social and economic progress achieved over decades
of initiatives by the people and advances in health can be
significantly degraded by disasters.
Be it an act of God or act of Man, a mind-boggling spec-
trum of disasters wreck havoc in the Indian subcontinent.
The disturbing fact is that even in a region like South
Asia, where poverty, deprivation and death due to disasters
is a very common feature of life, India remains the worst-
affected country. In fact, the frequency of all categories of
disasters, varying from epidemics to road accidents, fires
and perennial droughts and floods, increasing act of
senseless terrorism has resulted in a multifold growth of
injuries, disabilities, diseases and deaths, disrupting life-
supporting systems and adding to the ill health, social and
economic burden of already impoverished people.
Between 1988 and 1997, disasters killed on an average
5,116 people and affected 24.79 million every year in India.
In 1998, 9,846 people died and 34.11 million people were
affected by disasters.4 Experience and study tells us that
the actual figures greatly exceed the documented ones. The
cities are surrounded by industrial areas which have stocks
of inflammable materials like inflammable chemicals, gas
storage fuel for furnaces and power generators, acrylic,
woolens, textile yarn and fabrics, etc. The towns also have
huge stocks of gadgets, electrical instruments not maintained
or scrutinized for safety. The extensive electrification is
being done haphazardly which is prone to fire accidents
due to short circuits.
The National Building Code of India lays down a set of
minimum provisions to which the buildings should be
designed to protect the safety of the public. The regulations
can be adopted immediately or enacted for use by various
departments, municipal administrations and public bodies.
These guidelines become mandatory provisions once the
state governments adopt the code through legislation. Many
states like Tamil Nadu, Karnataka, etc. have passed fire
service acts to ensure fire safety of buildings.
Through this act, the fire services are empowered to
issue Fire License/No Objection Certificate to building
owners which enables them to get clearance for occupation
from Metropolitan Development Authority/City Municipal
Corporation etc. The fire license is issued based on the
adherence to National Building Code provisions with respect
to fire safety. In case of industrial buildings, the requirements
of factories rules, Oil Industry Safety Directorate guidelines
should also be complied with additionally, wherever
applicable.
Despite the above mandatory requirements, non-
implementation of fire safety in all buildings, residential as
well as commercial, from the stage of planning is totally
missing. Fires keep on happening frequently in less
hazardous non industrial buildings in India.

Burn Injury Management in Disasters: Indian Perspective
547
Unregulated erection of temporary structures commonly
known as “Shamianas” (make-shift tents) is done in India
for all kind of functions from marriage to award giving
ceremonies, including government functions. They
extensively use inflammable material with loose, exposed
and temporary electrical wirings making them tinder boxes
which go up in flames very easily.
A review of fire safety in India reveals that the available
fire services are showing signs of “deficiencies in terms of
manpower and infrastructure”. Instead of growing and
modernizing itself to ensure the safety of life and property,
the usual fire services have depleted or become deficient
for the growing population. We have, beyond doubt, made
the world a dangerous place to live in.
Simply defined, a disaster occurs whenever the need
exceeds resources. India does not have a very well developed
health infrastructure and has skewed distribution of available
resources. There are a few fully equipped and staffed urban
centers especially for burns injury. Therefore, any fire
accident or act of terrorism resulting in large number of
burn injury victims becomes a disaster. Worldwide, such a
surge in burn injury causes significant morbidity and
mortality. Developed and undeveloped health system
determines the response and humanitarian action. India
remains a resource poor country where public health system
has not paid any emphasis on special development of
facilities. Burns cause significant morbidity and mortality
and their prompt and swift management can reduce death
and disability and therefore, the need to have a plan for
burn injury management in burn disaster. Lessons learnt
from tackling various disasters have led to some improvement
of public systems and realization of organized management
for burn injuries. Preparation for burns disaster will help in
improving and establishing burn care units. Therefore, every
burns unit should prepare a burns disaster plan and it must
be integrated with disaster planning of the emergency
department and trauma care unit of the hospital. If possible,
it should develop pre-hospital system or get linked with
emergency pre-hospital system. It should be an integral part
of the state and national disaster management plans.
The study and analysis of factors that cause a disaster,
the characteristics that shape its evolution, the effects on
the population and the natural environment, the instruments
that can mitigate their effects and the various ways of re-
establishing the optimal living conditions of the persons and
communities involved have led to the creation of the new
science of Disastrology. It studies disasters from all points
of view and establishes guidelines for their management.
“Disaster medicine” considers the health aspects of
disasters, in particular the study and collaborative application
of the various health disciplines involved, i.e. from pediatrics,
epidemiology, communicable disease, nutrition, public health,
emergency surgery, social medicine, community care,
humanitarian relief and international health, to the prevention,
immediate response and rehabilitation of the health problems
arising from disaster, in co-operation with other disciplines
involved in comprehensive disaster management. These
approaches have led to the scientific elaboration of disaster
planning and response. This has been gradually transformed
from a combination of ad hoc and humane actions for the
stricken persons into an efficient managerial system
throughout all the phases and aspects of the disaster, from
prediction and prevention to preparedness, immediate
medical response, assistance and rehabilitation.
Masellis described disaster as a serious and immediate
threat to public health. He divided management and the
rescue operations for i) a fire disaster or thermal agent and
ii) a burn disaster.
Fire Disasters
It is a sudden vast ecological breakdown due to fire between
man and his environment and needs extraordinary efforts
to control this breakdown. This may not always result in a
very large number of burn victims. Californian forest fires
and Australian bush fires are the typical examples. Although
a fire disaster need not necessarily reach catastrophic
proportions, it will present some of the characteristic aspects
of a disaster because of the highly destructive action of fire
and the considerable number of victims. The surviving
casualties will have mainly serious and extensive burns
requiring immediate rescue procedures that cannot always
be provided by local resources.
A fire of vast proportions can, moreover, cause damage
to the surrounding environment by the massive production
of heat and the emanation of burn gases and fumes. Smoke
and gas, because of their suffocating action and their direct
action on the airways, represent other specific danger
elements. The danger of smoke and gas is generally
underestimated by the population.
Burn Disasters
It can be defined as the overall effect of the massive action
of a known thermal agent on living beings. Burn disaster
can be either part of a natural disaster like lightening, forest
or bush fires, earthquake, volcanoes which are rare or man

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Principles and Practice of Burn Care
made as airplane crash, building fires, explosions, fires in
inflammable material industry, during transport of
inflammable material or thermonuclear. A burn disaster is
characterized by a high number of fatalities and of seriously
burned patients with a high potential for mortality and
disability. Its extent may be aggravated if appropriate rescue
operations are delayed. Some decisive factors involved here
are the type of causal agent, the type of pathology caused,
the overall characteristics of the harmful action of the
thermal agent, the immediate evaluation of its gravity in
relation to emergency care and the modalities of rescue
operations.
In burn disaster, two concepts are, therefore, involved,
viz. the pathological condition, i.e. extensive burns and the
high number of persons injured. Its extent depends on the
potentially large number of fatalities which is related to the
considerably large number of persons involved, the
seriousness of their condition and above all, the early initiation
of emergency therapy. Advances in science and technology
have increased the risk of accidents and transfer of energy
to nearby population. We are confronted with possibility of
use of harnessed powerful sources of energy and their
accidental or malicious use to unleash the magnitude of
destruction which can be appalling and shocking as in the
case of World Trade Centre terrorist attack. Such disaster
terrorism and shift in war strategies have contributed to
startling number of burn injuries or burn disasters. Therefore,
a burn disaster is essentially a medical disaster for
communities and the state and infrequently for the countries.
It can be defined as any catastrophic event in which number
of burn victim exceed capacity of local burn center(s) to
provide optimal burn care. To tackle this disaster, one needs
preparedness, planning, resource allocation, communication
and delegation of duties.
It can become a “humanitarian emergency” when the
social, economic and the medical infrastructure is disrupted
or destroyed and more and more victims of burn injury are
generated which cannot be dealt with the already
overburdened or poorly efficient and depleted medical
systems. Such, on going humanitarian crisis exists today in
Iraq, Sudan and Afghanistan because even small number of
burn injuries constitutes a big disaster there.
What constitutes a burn disaster in terms of magnitude,
number and extent of burns is not defined. Few burn
casualties may be a disaster in India in far flung places
without medical facilities while a comparatively larger
number of burn injuries may be dealt with satisfactorily in
large cities. In USA, more than five victims of burn injury
sustaining more than 20% TBSA burn is a disaster and
enough to trigger disaster response, while any fire incident
causing more than 25 or more deaths is a major disaster
(Masellis). As said earlier, if the local facility is overwhelmed
by the number of burn injuries, then it is a disaster.
Most of the burn disaster are contained and local and
rarely can be catastrophic as in case of war or large explosion
nuclear leak. Study of epidemiology of burn disasters makes
it unlikely. It is expected that the planning for general
management of disasters will cope with such rare eventuality.
But even in countries which have such large scale disaster
plans these plans remain untested. From the burn physician’s
point of view, planning would essentially focus on medical
treatment and intervention in case of large burn injury
disaster. The most important aspect from public health
planning would be to support medical infrastructure and
develop burn care units to be operational in normal times.
EPIDEMIOLOGY OF BURNS DISASTERS
IN INDIA
The greatest fire tragedy in India was the Bombay Docks
explosion of April 14, 1944. A fire occurred in a ship called
“Fort Strikine” in the Victoria Docks. The ship was carrying
ammunition and explosives. A series of several explosions
occurred, destroying about 14 ships. That day 336 people
died and 1,040 were injured. The explosions were recorded
over 1,000 miles away at Shimla. The total loss of property
according to the then calculations was approximately rupees
100 crores. This was the worst explosion in the history of
fire services in India which destroyed buildings in over 100
acres of Bombay Docks area. The death toll in the
catastrophe was estimated at about 500, including 66 gallant
officers and men of the Bombay Fire Brigade. Those gallant
officers and men laid down their lives in the cause of safety,
welfare and prosperity of the community.
According to a conservative estimate of the Home
Ministry, 4,000 human lives were lost along with the loss
of property worth Rs. 588 crores due to fires in 1997. The
actual figures may be much more, as the information
collected was not exhaustive (Information Bureau, Govt.
of India). Following are the details of major burn disaster in
India since 1990.
April 16, 1990: Seventy people were burnt to death as a
shuttle train catches fire near Patna.
Oct 10, 1990: Forty persons were killed in a fire in a train
near Cherpalli in Andhra Pradesh.

Burn Injury Management in Disasters: Indian Perspective
549
Dec 23, 1995: Four hundred and forty-two people, majority
of them children, were burnt to death at the Rajiv Marriage
Palace in Dabwali town in Haryana. During the function of
a local School there, the tent put up by the marriage palace,
which had no permission to do so and flouted all fire safety
norms, caught fire and collapsed over 1,000 people.
June 13, 1997: 59 people die of asphyxia in Uphaar cinema
hall fire, which broke out during screening of Hindi movie
‘Border’. Over hundred persons received injuries in the
subsequent stampede.
May 10, 2003, fire in a hosiery factory, godown in Khud
Mohalla, Ludhiana claimed 20 lives besides leaving around
100 injured.
February 27, 2002: 58 persons, including 25 women and
15 children charred to death in the S-6 coach of the train
May 15, 2003: A burst stove caused a devastating fire that
swept through a speeding passenger train in Punjab, killing
40 people and injuring more than 50.
Jan 23, 2004: 59 persons killed and injuring 60 people in a
short circuit ignited fire in a marriage hall in Srirangam, a
famous Hindu temple town 200 miles south of Chennai,
Tamil Nadu
July 2004: 94 children perished and 100 injured in a
devastating school fire, Khubhkonam Tamil Nadu.
April 10, 2006: Major fire killed at least 50 people, 115
people were injured in a blaze at a consumer fair in the
industrial city of Meerut, Uttar Pradesh, 70 km from New
Delhi.
Dec 10, 2008: An over loaded bus carrying 100 people
broke down and caught fire. 60 people killed due to fire and
40 severely burnt.
Increasing incidents of terrorism involving explosions
in recent times have resulted in multiple system trauma along
with burn injuries.
The year 2008 claimed more than 210 lives and left
more than 600 injured due to terrorist attacks in Jaipur
(May 13th), Ahmedabad (July 26th), Delhi (September 13th)
and Guwahati (Oct 30th). The worst terrorist attack on
India occurred on 26th November, 2008 and left 182 dead
and more than 300 injured and torched several five star
hotels.
In India, during Diwali on 28th October 2008, more
than 1000 fires were reported from all over country and
firecrackers, most of them unsafe, worth rupees 600 crores
were burst. There must be more than 5,000 injuries and at
least 100 of them very serious. The fire cracker industry in
India is 1,000 crores and as mentioned 600 crores worth
crackers are spent around Diwali alone. The fire cracker
industry is becoming more and more unregulated and is
experimenting with newer and dangerous combinations to
compete with Chinese firecracker industry. We create and
live this disaster every year.
We do not have records of burn injuries in India. It is
estimated by extrapolation of population figures that there
are 7, 00,000 major burn injuries every year and about 1,
20,000 die of burns. We do not have adequate facilities in
terms of bed and personnel to provide them with optimal
care. So, there is an on going burn disaster in India.
VULNERABILITY ASSESSMENT AND RISK
ANALYSIS
Risk analysis and vulnerability assessment involves the
creation of a scenario for each potential disaster in terms of
exposure, loss of life, damage to property and the geographic
distribution of each hazard. Any monitoring facility,
regulatory regime and counter measures available for each
disaster are accounted for in this analysis.
Mass casualties from burns occur when fire and/or
explosions interface with large numbers of people (Figs 39.1
to 39.3). In this context, the most likely hazards identified
for India are fires, explosions, transport, train accidents,
inflammable material trucks and tankers, mass gatherings
especially in temporary structures, high-density urban
dwellings, offshore oilrigs and acts of civil disturbance and
terrorism. The recent fire disasters show that in indoor fires
where the victims are trapped, immediate morbidity and the
Fig. 39.1: Historical picture depicting a major fire

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Principles and Practice of Burn Care
very high rate of death was due to hypoxia (inhalation
injuries). Intoxication due to carbon monoxide poisoning
and other toxic fumes led to inability and incapacity to react
and escape and therefore, high indoor death rates as in
Uphaar cinema fire tragedy.
Natural disasters such as rural fires and earthquakes
fires are rare in India. In recent years, shift in terrorism to
urban areas using unconventional ways to wrought
destruction through explosion and fire as in the cases like
9/11World Trade Center in New York (2001), Bali (2002)
and Madrid (2004). All three events highlight the fact that
many patients suffered significant burn injuries as well as
other multiple system traumas. Indeed, in the Bali bombings,
62 patients were admitted across Australia, occupying all
adult burn beds. This extra patient surge occurred on the
background of normal operations where severe burn patients
from other incidents also required care. As India is becoming
the most common target of international terrorism with mass
casualty burn disasters occurring with catastrophic
consequences, it is important to have formal plans at both a
State/Territory and national level.
Historical analysis of terrorist events, where improvised
explosive devices (IEDs) have been used, consistently
demonstrates that up to 10-15% of the total live casualties
have severe burn injury and other multiple trauma injuries
requiring critical care/tertiary level burn services.
On the basis of scenario planning and historical
precedent, in a worst case scenario, with 2,000 live
casualties, India will have to manage a surge of up to 300
severe burn injured patients in case of the worst explosive
attack. This will significantly challenge existing systems.
Burns injuries in a disaster or burn injury disaster can
not be viewed only as a medical emergency and their
management cannot be done in isolation. With the increasing
awareness about scientific ways to manage a disaster, it
becomes imperative that management of burn injury is an
integral part of overall disaster management.
The limited scope of interpreting a burn injury disaster
from hospital or health care point of view has to change to
holistic disaster planning.
Therefore, all burns disaster plans have to be part of the
comprehensive, multi-hazard disaster management plans,
emphasizing disaster management response, disaster
awareness and education.
APPROACH TO DISASTER MANAGEMENT IN
INDIA
The increasing frequency and fury of natural disasters has
shaken the policy makers of India and a high power
committee has been established to address the multiple facets
of natural and man made disasters in India.
Till recently, the approach to disaster management has
been reactive and relief centric. A paradigm shift has now
taken place at the national level from the relief centric
syndrome to holistic and integrated approach with emphasis
on prevention, mitigation and preparedness. These efforts
are aimed to conserve developmental gains as also to
minimize loss of lives, livelihood and property.
A typical Disaster Management continuum as shown
below, comprising of six elements i.e., Prevention, Mitigation
and Preparedness in pre-disaster phase and Response,
Rehabilitation and Reconstruction in post-disaster phase,
defines the complete approach to Disaster Management
(Flow chart 39.1).
Government of India (GOI), in recognition of the
importance of Disaster Management as a national priority,
Fig 39.2: Firemen in action during a fire in a high rise building
Fig 39.3: Seen of the dhabwali fire disaster

Burn Injury Management in Disasters: Indian Perspective
551
set up a High-Powered Committee (HPC) in August 1999
and also a national committee after the Gujarat earthquake,
for making recommendations on the preparation of Disaster
Management plans and suggestions for effective mitigation
mechanisms. The Tenth Five-Year Plan Document also had,
for the first time, a detailed chapter on Disaster Management.
Similarly, the Twelfth Finance Commission was also mandated
to review the financial arrangements for Disaster Management.
On 23 December 2005, the Government of India enacted
the Disaster Management Act (Flow chart 39.2), which
envisaged the creation of the National Disaster Management
Authority (NDMA), headed by the Prime Minister and State
Disaster Management Authorities (SDMAs) headed by
respective Chief Ministers, to spearhead and implement a
holistic and integrated approach to Disaster Management in
the country.
National Institute of Disaster Management
(NIDM)
Under the NDMA and through disaster management act, a
National Institute of Disaster Management (NIDM) was
created. It is a premier national organization working for
human resource development at national level in the area of
disaster mitigation and management. The NIDM came into
existence on October 16, 2003 by a Government of India
order upgrading the National Centre for Disaster Management
(NCDM), which was located at Indian Institute of Public
Administration, New Delhi. The NCDM was established by
the Ministry of Agriculture, Department of Agriculture and
Cooperation, Government of India in March 1995. The
NCDM had been functioning as a Nodal Centre for the human
resource development in the area of disaster management.
NIDM will be gearing up the national, state and district
level administration to tackle natural calamities and will also
be coordinating research projects, training programs and
will build a database on natural disasters with case studies.
India Disaster Resource Network (IDRN)
Under the national disaster plan, Ministry of Home Affairs,
Govt. of India, established India Disaster Resource Network.
This is the net work of net works. IDRN portal was launched
in September 2003 in collaboration with UNDP. Technical
support was extended by UNDP to systematically formulate
the resource inventory through an organized information
system designed to collate and assimilate information from
authorities in 563 district and 35 State/Union territories. The
on-line inventory clearly lists out sequential details on specific
equipments, types, their functions performed, human
expertise in search and rescue operations and contact details
of expertise and suppliers for prompt mobilization. IDRN
was designed as a web enabled information system to
provided updated inventory of related items every quarter,
Flow chart 39.1: Disaster management continuum

552
Principles and Practice of Burn Care
Flow Chart 39.2: National Disaster Management Structure

Burn Injury Management in Disasters: Indian Perspective
553
entered at two levels, i.e. at district and state level. The
portal has been hosted to the central server at National
Information Centre (NIC), who is providing technical
support to Ministry of Home Affairs. The portal has an on-
line dual accessible interface system for users from state
disaster management/relief and rehabilitation department
officials (Relief Commissioners), district administrators
(District Magistrate/Collectors) and other state and district
nodal officers, corporate members and public who can
browse the portal. The user can obtain catalogued
information as well as query based data and list of resources
available at district and state level. The on line inventory
user manual and details can be accessed at http://

On the IDRN, nation wide availability of beds for burn
injury can be listed along with trauma units and their surge
capacity. National Academy of Burns-India (NABI) should
provide authentic information after getting all the information
from the public and private hospitals on IRDN to be used at
the time of disasters. The list of burn care physicians should
also be provided area-wise with their contact information
for use during disaster.
Burn Disaster Response Team (BDRT)
At present no plan for burn disaster response team has been
made in disaster planning in India a whole or in any other
state. A burns disaster team can be raised in larger institutes,
e.g., Safdarjung Hospital in New Delhi, as they are the
repository of large number of trained burn care experts. At
least one team should be readied with personnel, equipment
and resources to be dispatched at short notice from the
department of burns and plastic surgery at Safdarjung
Hospital, which is directly under Central Government. It
will help dispatching such team promptly as sending an
international and interstate humanitarian mission requires
government permission.
Burn care is not optimal in all countries and even in
India only very few centers provide desired optimal care.
Therefore, there is a need to raise burn disaster response
teams. Government of India or NABI and (Burn Association
of India (BAI) should prepare a plan to constitute such burn
disaster response teams and offer these teams for national
needs in areas of deficient expertise or for international
humanitarian missions.
BDRT can travel at short notice to the disaster site and
carry out effective primary triage, first aid and execute safe
transport. BDRT should have a designated leader and team
members. The vehicles and resources should be planned
and earmarked.
IDRN can also enlist information about individuals and
agencies who can volunteer at the time of disaster and
humanitarian crisis.
To build a safer and disaster resilient India by developing
a holistic, pro-active, multi-disaster and technology-driven
strategy for disaster management, collective efforts of all
Governmental Agencies and Non-Governmental
Organizations are required.
National Disaster Response Force (NDRF)
The Concept: The Disaster Management Act has mandated
the constitution of a Specialist Response Force to a
threatening disaster situation or a disaster. This Force will
function under the National Disaster Management Authority
which has been vested with its control, direction and general
superintendence. This will be a multi-disciplinary, multi-
skilled, high-tech force for all types of disasters capable of
insertion by air, sea and land. All the eight battalions are to
be equipped and trained for all natural disasters including
four battalions in combating nuclear, biological and chemical
disasters (Fig. 39.4).
Present Organization: Presently this Force is constituted
of eight battalions, two each from the Border Security Force
(BSF), Central Reserve Police Force (CRPF), Central
Industrial Security Force (CISF) and Indo Tibetan Border
Police (ITBP). Each battalion will provide 18 self-contained
specialist search and rescue teams of 45 personnel each
including engineers, technicians, electricians, dog squads
and medics/paramedics. The total strength of each battalion
will be approximately 1,158.
Deployment: These NDRF battalions are located at nine
different locations in the country based on the vulnerability
profile to cut down the response time for their deployment.
During the preparedness period/in a threatening disaster
situation, proactive deployment of these forces will be
carried out by the NDMA in consultation with state
authorities.
There is an urgent need to establish national burn injury
response team which can be done as mentioned earlier at
few large institutes in the country. One of the ideal centers
to constitute such a team will be Safdarjung Hospital, New
Delhi as it is repository of largest number of burn specialists
and paramedical and the trainees directly under Government
of India.

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Principles and Practice of Burn Care
National Disaster Mitigation Resource Centers
(NDMRC)
The NDMRCs will be co-located with the NDRF battalions.
These will also serve as repositories for NDMR bricks of
relief stores for 25,000 affected people, in each of the nine
locations. These will cater to the emergent requirements
especially for the first 72-96 hours. At Kolkata and
Chandigarh, additional bricks of stores for 50,000 people
each will be kept for high altitude areas. These stores will
supplement the reserves maintained by the respective States.
In addition, these centers will assist in running mock drills
and capacity development programs. During disasters, they
will act as facilitators to the States/Union Territories in
deployment of central resources and provide much needed
additional link to the center.
NATIONAL DISASTER MANAGEMENT
GUIDELINES-MEDICAL PREPAREDNESS AND
MASS CASUALTIES MANAGEMENT (NDMG-MPMCM)
Medical Management of Mass Casualties is based upon ‘all
hazard’ concept where practically every Ministry/
Department will be playing a role directly or indirectly with
nodal ministry as Ministry of Health and Family Welfare,
Government of India. As per the National Disaster
Management Act, 2005, National Disaster Management
Authority (NDMA) is required to prepare Guidelines, based
on which, the Nodal Ministry will prepare a detailed Action
Plan for the better and effective medical management of
mass casualties. In view of evolving such Guidelines, a
National workshop on Medical Preparedness and Mass
Casualties Management was convened by NDMA in August,
2006 and various experts from the Center, State
Governments and NGOs participated. In this workshop,
the present status of the Medical Preparedness in the country
was discussed and future course of action was set up. It
was decided to articulate the MPMCM guidelines through a
document called National Disaster Management Guidelines-
Medical Preparedness and Mass Casualties Management
(NDMG-MPMCM). A Core Group of the experts from the
various fields related to medical management was constituted
under a Chairman to assist NDMA in preparing National
Guidelines for MPMCM. The core group has met for
deliberations and has yet to finalize its recommendations.
NDMA has observed some critical gaps in managing mass
casualties and issued fresh guidelines for the disaster and
need to adopt multi-disciplinary and multi-sectoral approach
for prevention/mitigation strategies so as to develop
capacities to improve response. It envisages strengthening
of about 200 hospitals from basic trauma care to advanced
tertiary care, all networked with pre-hospital care ambulances
to provide care during transit and hospitalize within the
golden hour.
Essentially, apex bodies of central government are trying
to associate other professionals. Surprisingly no associates
of medical fraternity, especially the burns care bodies like
NABI (National Academy Burns-India) or burns care experts
have been nominated. There is an urgent need for NABI to
take this issue with MP-MCM group. A model integrated
plan applicable to all districts of India for management of
burn injury mass casualty should be submitted. Making plans
in isolation will not be effective as NDMA is planning
disaster management to the level of districts through state
government.
The Section 23 of the Disaster Management Act 2005
provides that there shall be a disaster management plan for
every state. It outlines the broad coverage of the plan as
well as the requirements of consultation in the preparation
of the state plans. It also provides for annual review and
updating of the state plan, and enjoins upon the state
governments to make provisions for financing the activities
to be carried out under the state plans. It provides for the
departments of the state governments to draw up their own
plans in accordance with the state plan. The state plans
shall be prepared by the State Executive Committee (SEC)
in conformity with the guidelines to be issued on related
matters by the SDMA having regard to the guidelines laid
down in this regard by the NDMA and after such
consultation with local and district authorities and the
people’s representatives as the SEC may deem fit.
With assistance of UNDP and USAID under the SDMP
the states have been assisted to draw district and block
level DMP through the Panchayti raj institution. The DMP
has been prepared for 8643 villages, 1046 Gram Panchayats,
1818 blocks and 82 districts. More than 29000 elected
representatives have already been trained besides volunteers
at village level who are being trained. Besides this, 18,000
government officials, 865 engineers, 425 architects, 600
master trainers and 1200 teachers have already been trained.
Twenty nine states have disaster management facilitates
and plans finalized. 28 of them have created training institutes.
State of Gujarat, Maharashtra, Assam and Bihar have
finalized their disaster plans and have published them.

Burn Injury Management in Disasters: Indian Perspective
555
In an effort to create awareness and plan for future
management of disasters, disaster management has been
introduced as subject in class eighth and ninth by Central
Board of Secondary Education (CBSE), New Delhi.
In major cities (with a population exceeding10 lakhs),
municipal corporations have a large administrative system
including departments like engineering, public health and
revenue and sometimes fire services. These should provide
a good mechanism for coordinated response in case of any
crisis/disaster. Therefore, management of major cities should
be planned as a unit. In metropolitan cities it is also advisable
to make the urban metropolitan government directly
responsible for DM.
The Medical Preparedness and
Mass Casualty Management
The following points must be reflected in the state plan:
•
Listing of all hospitals and Primary Health Centers
including private nursing homes and their capacities.
•
Emergency casualty management plans at the local,
district and state level.
•
For effective management of big cities like Delhi and
Mumbai, nearby medical facilities must also be built into
plans.
•
Availability of mobile hospitals and/or plans for acquiring
the same. The state plan may also adopt the Generic
Categorization of Disasters with specific plans at the
state level by various departments to handle different
disasters.
Levels of Disaster
The levels of disasters have been categorized and
disseminated as L0, L1, L2 and L3, based on the ability of
various authorities to deal with them. Various color codes
relating to the level of alerts have also been assimilated. L0-
denotes normal times which are expected to be utilized for
close monitoring, documentation, prevention, mitigation and
preparatory activities. This is the planning stage where plans
at all levels from community to the State shall be put in
place. Training on search and rescue, rehearsals, evaluation
and inventory updating for response activities will be carried
out during this time.
Fig. 39.4: National disaster response battalions and training centers

556
Principles and Practice of Burn Care
•
L1-specifies disasters that can be managed at the district
level. However, the state and center will remain in
readiness to provide assistance, if needed.
•
L2 -specifies disaster situations that may require
assistance and active participation of the state and the
mobilization of resources at the state level.
•
L3 -disaster situations arise from large scale disasters
where districts and the state may not have the capacity
to respond adequately and require assistance from the
central government for reinstating the state and district
machinery.
•
Even though there cannot be water tight compart-
mentalization of responsibilities between states and the
centre, especially in the case of man-made disasters,
the participation by Centre will normally beat the L3
level. Most of the burn disasters would fall in L-1. or L-
2 types. The burn care facility in the district has to
coordinate with the district disaster plan (DDP). It has
to become part of the community based DDP. In case
of absence of the burn care facility, the local
Government and private medical facility will have to be
enlisted to provide initial care and plan evacuation to the
nearby burn facility.
Role of the Emergency Operations Center
(EOC)
Time bound action plans must be indicated for creating
facilities for environment scanning, intelligence gathering,
operations and logistics management under one roof for
holistic and efficient management of disasters at the state
and district level. Arrangements must be made and
procedures must be laid down for manning the EOC on 24
× 7 × 365 basis. The plan must also cover in detail the
indigenized Incident Command System at the state, district
and local body levels.
The disaster specific plans for mining, oil spills,
biological, chemical and nuclear has been made by some
States but no burn disaster specific plan has been made by
any state or city administration. It is felt that bodies like
NABI, with local burns care facilities, should develop burn
disaster plans taking into consideration the local facilities,
geographical conditions etc. A model burn disaster plan for
cities and rural area can be prepared and submitted to NDMA
coordinating the activities of various health disciplines to
prevent disasters, provide an immediate response to a disaster
and help in rehabilitation of victims.
BURN INJURY SCENE IN INDIA
In India, specialized burns care is available for the last 50
years but gloom prevails over this particular discipline,
marked by alarming morbidity and mortality. On an average,
burns centre of a public hospital is able to save patients
with burns below 40 per cent. Those having burns close to
50% have 50% chances of survival and very few cases
survive having burns beyond 60%. In West Bengal, the
survival rate of a 50% burn is a dismal 25%. This is in stark
contrast with the developed countries where patients with
more than 70 per cent burns also survive and the survival
rate of patients with 50 per cent burn is from 75 to 90 per
cent. There are estimated 32 burns units India which are
woefully inadequate. With around 7, 00,000 major burn
victims needing hospitalization and 1, 20,000 succumbing
to the injury, the meager 32 burns units in the country (of
which only 19 are said to be up to the mark with a low
mortality and morbidity rate), are not able to meet the
demands and render quality care.
India with a population of more than one billion needs
ten times more number of burns units in the country. In the
US, there are about 120 burn care facilities for a population
of less than three hundred million.
Burns care in government hospitals is plagued by lack
of infrastructure, whether it is sophisticated equipment,
availability of medicines, spacing between beds or the
manpower. With burns care needing the facilities of an
intensive care unit, some burns units are run without basic
equipment like ventilator, pulse oximeter, infusion pump and
patient weighing machine and skin graft mesher etc.
The burns unit is not something that the private sector
evinces interest with problems of high infection rates,
medico-legal work (with every burns case to be reported to
the police and requiring evidence in the court in case of
complications) and a long hospital stay.
While the chances of survival of severe burns patient
can be enhanced by skin grafting, burns surgeon rue that
cadaver donation of skin cannot be practiced with the non-
inclusion of skin in Transplantation of Human Organs (THO)
Act, 1994. Though burns surgeon did lobby to allow
cadaveric donation of skin, the government had turned down
the proposal on the ground that skin is a tissue and not an
organ and hence cannot be included in THO Act. Live skin
donation is hampered by unavailability of donors, the risks
associated with contacting AIDS and the pain and trauma
that the donor has to undergo.

Burn Injury Management in Disasters: Indian Perspective
557
Although there are more than 1200 plastic surgeons in
India who constitute a useful resource of trained personnel
in burns, most of them dedicate themselves to burns care
only partially. Not more than 40 burns surgeons are
exclusively dedicated to burns care. All the burns units in
government hospitals are usually full. Therefore, there is
hardly any surge capacity in specialized care units for burns
injuries in India
SURGE CAPACITY OF HEALTH CARE UNITS
Surge capacity has been defined as the “health care system’s
ability to manage a sudden or rapidly progressive influx of
patients within the currently available resources at a given
point in time. This term entered the disaster medicine lexicon
after “9/11” 2001 in America, and has become a key feature
of health disaster planning since the severe acute respiratory
syndrome (SARS) outbreaks, the rising threat of pandemic
influenza and the Madrid and London bombings in 2004 and
2005 respectively.
Mass trauma events in urban environments create surge
problems for hospitals in the first 4 hours, with the majority
of casualties likely to arrive at the hospital in the first
60-90 minutes. Health systems need to be able to meet this
increased demand after acute mass casualty events, with
an influx of patients who may require “specialized evaluation
or intervention” specially burns, including surgery for
penetrating trauma. As the epidemiology of traumatic events
will differ depending on the cause, any preparations to
manage a mass casualty event needs to be flexible enough
to deal with a range of disaster types, including infectious
disease emergencies and bioterrorism, with their more
insidious and later-peaking surge.
Meeting the challenges of surge capacity enhancement
calls for cooperative action at the complex interface between
clinical practice, health systems management, logistics,
facilities management and personnel deployment.
The US Health Resources and Services Administration
has set a minimum benchmark for surge capacity of
500 adult and pediatrics patients per million population for
infectious disease events and at least 50 patients per million
population sustaining trauma or burns in a mass casualty
event. These figures have not been validated and based on
other traumatic events, 100-300 patients per million may
be more accurate for burns or trauma. The consensus from
a series of articles on the “science of surge” in the November
2006 issue of Academic Emergency Medicine was that there
is little or no quantifiable measurement for managing an
acute “sudden impact” surge or the even less predictable
surge resulting from infectious disease emergencies or
obscure events.
Some of the measures which can be implemented in
case of huge surge are:-
•
Creating temporary hospital facilities within public
hospitals by having caches of medical supplies and
equipment available;
•
Using alternative health facilities, such as operating
theaters, beds and diagnostic resources in private
hospitals and day procedure units for the “walking
wounded” and “decanted” patients (patients already in
hospital who can be transferred elsewhere to make way
for disaster victims);
•
Using general and private health practitioners to provide
a range of care for the walking wounded and decanted
patients; and
•
Applying modified models of care, such as longer shifts
and extended scope of practice for nurses, allied health
practitioners and medical and other health students.
PREVENTION AND MITIGATION
Prevention is the most important public health tenet.
Pure disaster response alone is not sufficient and gives
only tiding away and temporary results at a very high cost.
Prevention and mitigation contribute to lasting improvement
in safety and are essential to integrate in disaster planning.
To avoid a mass burn casualty disaster, planning from
several key government areas is required in terms of
legislation and strict implementation.
Industrial, high-density, urban fires—all buildings should
have fire prevention strategies (sprinklers, smoke alarms,
and fire egress). All residents of the buildings should be
briefed on fire prevention and escape. This will be the
responsibility of state operated fire services.
It has been noted that although strict laws for buildings
and other structures exist, it is the poor implementation and
lack of will to maintain fire safety equipment which is the
root cause of failure for prevention. Most of the Indian
states have enacted their building codes and fire safety acts
to meet the requirement of high rise buildings.
Inspection of all buildings for their fire safety worthiness
should be done on regular basis. Fire escape plans must be
displayed properly. Every room of a public building should
have fire escape plan displayed.
The fire departments under state governments are not
well maintained and staffed. They need to have better
allocation of funds to strengthen fire fighting capacities.

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Principles and Practice of Burn Care
Although there is national fire safety institute in Nagpur but
more needs to be done in the field of fire safety.
Forest fires—Although forest fires are rare in India, these
fires have been reported sporadically from Himachal Pradesh
in north India and Tamil Nadu and Karnataka in south India.
Forest department, usually with district authorities, takes
care of these fires.
Transport—All transport devices should meet the criteria
for transport of hazardous materials. Responsibility: State
Road and Transport authorities, Ports authorities,
Commercial Aircraft Safety Authority should implement the
laws strictly.
Terrorism—To prevent a mass-burn disaster through an
act of terrorism, intelligence from agencies such as newly
created National Intelligence Authority, state intelligence,
border security forces and national body to fight terrorism
is required. In the wake of terrorist attack from sea,
strengthening of our coast by coast guards and navy is
required.
Information should be freely available to all residents on
what to do and where to go in the event of a major disaster
– i.e. a page in the telephone directory.
Mitigation Strategy
The mitigation strategy and plan focuses on the long-term
planning for disaster reduction. It deals with the issues of
continued commitment to hazard identification and risk
assessment, applied research and technology transfer,
investment incentives for mitigation and leadership and co-
ordination for mitigation. The mitigation strategy makes an
argument for better land use management, building codes,
traffic standards and health standards. These objectives are
to be secured through disaster legislation, mitigation
regulation and incentives for mitigation.
At the state and district levels, the same structure is
followed. The Disaster Management Plan calls for the
creation of a variety of facilities and resources which provide
support in the nature of infrastructure and organizational
requirements.
FUNDAMENTALS OF BURN DISASTER PLANNING
The burn injuries are common in mass disasters and terror
attacks.
The disaster plan is the best tool for preparedness.
Burn center care is the most efficient and cost effective
care of burn injuries.
Burn centers are not same as trauma care centers. Burn
centers are unique national resources. NABI, National
Academy of Burns-India, has the capacity to be a key
component in national disaster readiness for mass casualty.
Planning requires pre-existing health and medical
infrastructure and cooperation with local and state
Governmental agencies. Specialized burn care facility and
the team are the key around which the plan must be
developed. There has to be an active encouragement to lay
out plan for emergencies. All the stakeholders in burns mass
casualty should be made partners. They are police, district
civil authorities, fire department, emergency medical services,
ambulance services, transport providers, health department,
health centers, hospitals burns care units, private physician
and NGOs.
The objective is to provide optimal treatment of disaster
victim at the earliest. Though detailed plans through state
disaster management to the level of district have been
worked out, burn mass casualty management has not been
included. The burn care organization and the specialized
burn care units need to draw the attention of the state and
national planners and get themselves included in the disaster
plans. Scientific bodies like NABI should coordinate with
state and national authorities.
Burn disasters are usually man-made, usually confined
to local and limited geographical area. Consumption in terms
of man power and material are maximum for burn injury.
Even three to four patients have the capacity to strain health
facility. More than 20 patients will require intervention from
multiple well equipped facilities. In urban areas of India, it
is possible to cope with 20 to 30 victims of burn injury.
Magnitude of 100 to 200 victims will overwhelm the medical
system but we are not at all prepared for stronger surge.
We need to plan for large scale burn disasters, especially
with increasing terrorism in recent times with trend of
multiple bombing at multiple sites.
According to Masellis and Gunn, the following points
should be considered when planning burn disaster plans.
a. The time interval between the accident and initiation of
care must be less than two hours.
b. Triage of victims must be carried out by specialists, as
specialist alone can evaluate the gravity of burn injury.
c. Inhalation and combustion of gases, fumes and hot air
causing damage to airway alone can jeopardize survival.
d. Hypovolemic shock is induced rapidly and tissue hypoxia
induces irreversible changes in various organs. It should
be addressed immediately.
e. Burn may be associated with large wounds, fractures,
electrical injuries or blast injury lesions.

Burn Injury Management in Disasters: Indian Perspective
559
f. The overall assessment should be made not only on the
basis of dead but also on the number of injured and
those likely to suffer disability.
g. The place where disaster occurs may not be accessible
and no disaster plan to respond exists.
Of the 14 burn disaster studied by Arturson, only in San
Juanico tragedy of Maxico where LPG storage tanks caught
fire, more than 600 were dead with count of injured
exceeding 7,000, the worst burn disaster on record in recent
history, the disaster plan was in place .
Immediate care is provided by people present at the
scene of the disaster, who may be survivors or passers by.
These first responders are later guided by trained health
care workers who arrive at the site. On site management
includes:
Immediate relief and first aid: Immediate assistance,
provided in first 2-3 hours by the people preferably by trained
nurses, physicians and volunteers, is fundamental to
prognosis of burn patients. More complex and organized
relief may take 6-7 hours to reach. It may be too late for
burn patient. When burn casualties exceed the local ability,
a major disaster should be declared. District disaster plan
will take about 20 burn patients. In case of more casualties,
the state plan should be activated. All the agencies should
be utilized and educated about their roles and responsibility
to avoid chaos at the scene.
UTILIZATION OF MEDICAL TRIAGE
Ambulance staging with a basic aim of maximal use of
resources, efficient and safe transport.
Early notification and information to hospitals.
Utilizing an existing point of entry to activate disaster
plan.
TRIAGE
Sorting out and classifying casualty of war or any other
mass casualty is known as triage. It is done to determine
the priority and proper place for transfer. Triage is most
aptly applied to burns as burn injury is to some extent
quantifiable.
Triage is the cornerstone of effective burn disaster
management and is done at the disaster site by staff with
knowledge of burn treatment. Triage takes into consideration
the total number of patients, bed availability and
transportation capacity. The guiding principle is to treat those
who are most likely to survive or can benefit the most from
treatment. Thus, triage standards address who receives care
and when care is provided or the urgency with which it is
provided. Triage is performed most often by first responders.
Triage begins in the field, if there is a fixed event site;
however, it also occurs within care settings, such as hospitals
and alternate care sites, where individual victims may present
themselves for care independent of organized responses.
Secondary triage also may be necessary within a facility,
such as a hospital, as demands on the system grow. Several
well-established standards for triage are currently in use.
Triage systems include START; Jump START (a pediatric
modification to START); and Sacco score system. Each
system seeks to establish a small number of categories
among victims that indicates the urgency with which they
should be treated. Colors are often used to represent the
categories—for example, red (immediate care); yellow
(delayed); green or white (ambulatory and minor injuries);
and black (dead and/or “expectant).
The adequacy of the triage system used depends on the
nature of the event and the population affected. For example,
systems such as START and Jump START are trauma-
oriented and may be effective in an explosive event.
In case of burn disaster or a disaster with burn injuries,
the most important aspect would be to segregate patient
with only burn injury or burn injury associated with other
injuries for examination and triage by burn specialist or
physician trained in burn triage. If the incident is small with
limited casualties, ambulance trained paramedical will carry
out primary triage and transport.
Triage should be prognostic, and patients should be
categorized on the basis of age, extent of burns and site of
burns and presence of inhalation injury. Although there are
no specified triage criteria but recommendation for
transferring patients to a burns unit for satisfactory
management is the guiding principle, which are as follows:
•
Group I—Minor burns (< 10% of total surface area in
children, < 20% in adults) to non-critical areas.
Assigned to—Outpatient care, dressing, tetanus
prophylaxis.
•
Group II—Minor burns to critical sites (face, hands,
genitalia)
Assigned to—Short hospital stay, special wound care or
operation.
•
Group III—Major burns (20-60%)
Assigned to—Admission to burn unit, intravenous
resuscitation.
•
Group IV—Extensive burns (> 60%)
Assigned to—Lower priority for transfer.
•
Group V—Minor burns with inhalation injury or
associated injury.

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Principles and Practice of Burn Care
Assigned to—Oxygen, intubations, transfers to intensive
care unit.
The patients in groups III and V are evacuated first,
followed by group IV. Group II cases are evacuated at the
end. Group I cases are either discharged after first aid or
asked to make their own way to the nearest primary care
center. Once the surge capacity of nearest burn center is
exhausted, transfer to another center. If the surge is too
huge, then a trauma center serves as next level to provide
treatment.
Tele-triage can be done by getting in contact with any
tertiary care unit where a burn specialist can guide in triage
and initial management of the patients and the process of
preferable transport can be initiated. There is a need to train
primary physicians and all emergency medical officers in
the early management of burns and the method of triage.
An organization like NABI can play a very vital role in this
education.
As mentioned earlier, ideally the triage should be done at
the site of accident itself or should be set up at a nearby
dispensary or health unit. In India, there is no instance where
the triage has been used or set up. Patients have been loaded
and taken to nearby facility where some sort of triage based
transfer has been done.
COMMUNICATIONS
Communication during disaster is the most vital tool. It is
desirable to have on line voice communication to ambulance
service to burns unit, hospital coordinator burns surgeon,
trauma center individually and collectively. In some
developed countries, this aspect is already operational, e.g.
INFOBRUL in France, NDMS in the US, Argo in Italy. Like
USA, Germany has enhanced centralized system which
communicates to fire ambulance service and hospitals and
police at the same time. In India, none of the states or cities
has tried to develop and use communication and command
centers. The communication command centers should be
developed and manned by police and civil administration. It
should have central data bank about ambulances evacuation,
transport availability, disaster teams locally and hospital beds
availability. It should be manned 24 hours by personnel trained
in disaster management. The best way to keep this
communication center developed is to use it on daily basis
for routine distribution of patients of trauma and routine
emergencies. In India, under disaster plan, district control
room (DCR) and emergency operations center (EOC) are
being developed. The state of Maharashtra has put
Communication network comprising wireless (VHF) and
satellite (VSAT) networks covering the entire state and
computerized disaster management information system
using geographic information system (GIS) applications.
District Control Rooms: District Control Rooms are to be
established in each collectorate of the state. The control
rooms serve as nodal facilities for directing operations in an
emergency situation. The most important is to develop links
to organization capable of mobilizing carriers for transport
of patients and send prior information to the hospitals of
patients it is likely to receive. The first information usually
received by these center will trigger disaster management
response.
Emergency Operations Center (EOC): The Emergency
Operations Center is a well-equipped and modern facility
located at the state government headquarters. The EOC is
the hub of activity during a disaster. Its systems and
procedures are designed in such a way that information
can be promptly assessed and relayed to concerned parties.
As the master co-ordination and control point for all counter-
disaster efforts, the EOC is the center for decision-making
under a unified command. It is to be linked with all district
control rooms.
MANAGEMENT AT DISASTER SCENE
In an episode of disaster, the information should be passed
on to police and district administration. In India, in all
disasters the management is taken over by police and district
civil authorities or in worst cases by the paramilitary and
military forces.
Evacuation and transport: First task is to find, extricate
and transport victims usually by first responders or by fire
services who are professionally trained. The effort should
be to recruit all those who can rescue because early rescue
is the key to greater number of lives saved. The response
plan should take into consideration the activation plan for
explosions and industrial accidents especially in districts
having petrochemical and refinery industry. If the disaster
occurs in a remote area or the district has hardly any capacity
to deal with large number of burn victims, then establishing
of field hospital should be considered. In India, as mentioned
earlier, field hospital with the disaster management team is
being readied. In normal circumstances, the response is to
load and go to the nearest health facility. The “load and go”
evacuation system must never be used, especially in burn
disasters. It causes great hold-ups in transport, a chaotic
use of specialized beds and considerable risks for patients

Burn Injury Management in Disasters: Indian Perspective
561
who receive resuscitatory treatment only after long delays.
If possible, the primary triage should be conducted near the
scene of disaster and evacuation should be prioritized so
that the scarce bed capacity at the hospital is not over
burdened and low priority patient may choke the system.
Modern disaster management plan should effect
controlled and safe transportation of burn patient to
meaningful destination. Early information and notification
should be sent to potential burn facility to receive patient.
Emergency transport of burn patient is to be coordinated
with rescue organization. It may be practical to transfer to
the nearest medical facility for thorough assessment and
life saving treatment of respiratory and airway management.
Burn injury tolerates transport best on the day of
accident. Ideally all victims should be transported within 60
minutes. Late transfer is best done on third or fourth day
before sepsis sets in. Mass burn casualty in urban areas
must take into consideration traffic jams due to disaster.
Therefore, corridors of fast transfer to hospital should be
worked out before hand and if possible civil authorities
should keep access to hospitals clear. Traffic jams can also
affect arrival of staff to the hospital for disaster management.
In India, there is no provision of air or helicopter evacuation.
It is only rarely done for very important persons and in rare
circumstances.
When military forces are involved, there is a need to
establish regional helicopter evacuation services because it
is rapid and are not hindered by chaos on the ground.
When the surge is large and in remote areas, establishing
a field hospital should be considered. Field hospitals which
can be flown rapidly and established are only available with
army and para military forces. As mentioned earlier, the
national disaster plan is building and strengthening these
field hospitals with special battalions.
Burn facility surge capacity and Hospital Emergency
Incident Command System (HEICS):
Burn patients are best cared in burn units and there would
always be scarcity of specialized beds and expertise for the
treatment of extensive burns. Traditionally, the role of burn
units is to provide medical management to the patients who
arrive or get admitted. With disaster planning, the extended
role is to keep team ready and send them to disaster scene
to help evacuation, triage and initial management, to
coordinate and focus on leadership within medical
component.
Burn units rarely have low occupancy. Therefore, there
should be an emergency plan to shift and evacuate existing
burn patients to accommodate mass burn casualties. The
thumb rule should be to have at least 50% more capacity to
accommodate. As the burn units are usually located in large
hospitals, the hospital should develop and have Hospital
Emergency Incident Command System [HEICS] in place
and this should be tested for burns mass casualty. HEICS
provides responsibility oriented chain of command which
is charted and available with every one following case of
accident or emergency. It provides for Prioritization of duties
with the use of Job Action Sheets. The Job Action Sheets
are position job descriptions which have a prioritized list of
emergency response tasks. The Job Action Sheets also serve
as reminders of the lines of reporting and promote the
documentation of the incident.
•
A dependable chain of command.
•
Improved communication through common language.
•
Flexibility.
•
Prioritization of tasks.
•
Organized documentation system.
•
Effective mutual aid planning.
•
All acute care hospitals should develop and begin using
the HEICS structure.
HEICS commander should be in contact with emergency
operation centre coordinating initial care and evacuation.
In India, except for corporate hospitals, the HEICS is
not established. It should be mandatory for the hospitals to
have HEICS system in place and its details available with
emergency operation center and the district disaster plan.
All burn units should have plans to increase bed capacity
by 50% in case of disaster and plan to evacuate more stable
patients elsewhere in the hospital. If required, trauma facility
can be utilized and all surgical beds can also be added to
accommodate victims.
Personnel/Staffing
Staffing is the basic requirement for treatment of burns.
Advance plan can include short summoning of resident staff.
The plan should ensure that there are adequate numbers of
trained personnel to give initial resuscitation to burn victim.
Education regarding simple management of minor and
moderate burns should be imparted to all doctors and nurses
out side the burn units so that they become a great resource
at the time of disaster. In the hospital, a mixed team of
physicians is an asset as they can take care of initial care
like establishing intravenous access, intubations,
catheterization, initial dressings, etc. The senior surgeon
should immediately calculate requirement of staff in coming

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Principles and Practice of Burn Care
days, requirement of operation theaters and requirement of
dressing change. Volunteers always come whenever there
are disasters, Goodness in people is spontaneous. There
should be plan to coordinate and supervise these volunteers.
A team of hospital staff should be designated to do so, so
that requirement by the hospital can be communicated to
the volunteers and NGOs. They can be great asset and can
serve as clean up crew, help in transport, traffic control,
stretcher bearers, managing relatives and friends, give
information about victims, managing the dead and help
disposal of bodies.
Advanced Burn Life Support (ABLS)
Advanced burn life support (ABLS) developed by American
Association of Burns is an excellent tool. It is desired that
NABI develops such a course and through its own effort
and the burns units all over the country imparts such training.
Trained personnel are scarce in disaster; so they should be
used wisely. Having single caregiver, usually a nurse or
paramedic, taking initial care, intravenous fluids, pain control,
tetanus toxoid, airway maintenance, ventilation and
documentation is desirable. In case of remote places with
non-availability of burn expert, telemedicine facility can be
used to give advice and consultation on daily basis. NABI,
with Safdarjung Hospital, New Delhi and other burns centers
which are adequately staffed, can establish burn telemedicine
centers as national resource.
Arturson gave an analysis of San Juanico tragedy in
which 7,000 people were injured, 2,000 were hospitalized,
625 had severe burns, 300 died immediately, 250 died in
hospitals, later. 6,000 were evacuated and about 7,000 were
involved in rescue in first 48 hours. Of these 200 were fire
fighters, 1,000 were physician, 1,300 were paramedics,
1,800 were nurses, 2,000 were military personnel, 750 were
drivers and helicopter pilots. The plan should have provision
for such large mobilization response and coordination.
Handling of relatives and mass media should be relegated
to non care giver personnel. Such resource persons should
be identified and should be designated beforehand; they
should be well versed with press and multi-lingual. Handling
of media and giving regular feedback to them about
management is very important and it should be integral part
of the disaster management. It helps later in secondary
mobilization of resources like blood donation and
mobilization of volunteers.
Supplies, Equipment and Stockpiles
It is recommended that the disaster plan should take in
consideration the supplies and equipment available. In a
resource rich country, supplies and equipment can be
warehoused but in a country like India where health facilities
are always under crunch, it is not possible to make such
warehouse or stockpile. The burn disaster may increase
the demand on supply and just on time supply system may
not be able to keep pace with the demand. The concept of
emergency kits for disaster should be an integral part of the
plan and it must make provision for at least 50% surge and
its maintenance for few days. It should include all necessary
supplies for initial care of burn patient and this involves
investment of time and money to initiate and then maintain
and rotate it.
Other concept is to maintain emergency kits at a regional
or central stockpile depot. These can be used to air drop
wherever the need of these kits arise including remote areas
and where the rescue and emergency burn management
team are dispatched or field hospital has been set up. NABI
and other burn experts should approve of such kits and get
them stockpiled in regional response centers.
Exercising the Plan
Disaster plans usually fail because the dummy runs or mock
exercises are not conducted. The dummy runs help in
identifying gaps and evolve methods to remedy them. These
exercises are essential for role clarity of the stakeholders
concerned at the district level and for synergizing
coordination of various emergency support functions. A
simulation of disaster should be carried out frequently to
keep in preparedness. It should involve pre hospital
ambulance and evacuation services, hospital based persons,
application of HEICS and field teams which are supposed
to reach disaster site. The entire system should be tested
for seamless operation. The teams should meet frequently
for desk top exercises. In India, now through disaster
management planning at all levels the mass casualty training
is being imparted although their coordination and actual
application is yet to be tested.
Medical Response to Mass Burn Casualty
The most common burn mass casualty usually occurs in
urban areas or nearby urban areas. It is only rare to have
Ural train gas pipe line tragedy in Russia which occurred in
remote inaccessible area. Sometimes, the tragedy can strike
in a country or areas where there are no facilities to handle
mass burn casualties as happened in Bali Night Club bomb
explosions. In India, except for Dabwali fire tragedy, most

Burn Injury Management in Disasters: Indian Perspective
563
of the fire accidents leading to burn casualties occurred in
urban areas where rescue and transport was rapid but not
organized. They all followed load and go policy to nearby
medical facility without any triage.This leads to choking of
emergency services which are not geared to mange such
large numbers and the emphasis shifts to severe burn more
than 60% TBSA. Lack of awareness about inhalation injury
and being unprepared to handle large numbers of inhalation
injuries led to high mortality in Uphaar cinema fire in Delhi.
Medical response depends on information reaching the
hospital about the incident. It should happen through
emergency operation centers. The other information is about
the size of disaster and the type and number of casualties
expected so that appropriate HEIC can be initiated.
The medical response through trained paramedics or
trauma response team on the scene of incident is done in
three phases:
1. Primary Triage
2. Ambulance staging and
3. Establishing first aid post for severely burned.
The rescue and extrication should be ideally handled by
fire department or other responders trained in entering
buildings on fire and how to handle smoke and low visibility.
The guidelines as enumerated by Masellis for immediate
care of burn patient are as follows:
Guidelines for Immediate Care of Burn Victim
•
Self control
•
Self protection
•
Qualitative assessment of burn
•
Quantitative assessment of burns
•
IV fluid therapy
•
Analgesic therapy
•
Bladder catheterization
•
Pressure relieving incision –escharotomy
•
Reexamine the patient
•
Hospital or burn center transfer
•
Whosoever has been exposed to fire and have burns
even minor to be examined for Inhalation burns
After the primary triage, patients are shifted to nearby
hospitals as there is no time to carry out expert secondary
triage. The policy should be on first come first served basis
because true priority cannot be actually assigned till the last
patient has arrived there. Transfer to other centers, once
the capacity of nearby center is full, should be organized
through emergency control center.
Griffith has recommended the following triage and care
plan. It can be of use in transferring and ambulance staging
(Table 39.1).
TRIAGE CRITERION AND CARE PLAN
Except for minor burns all patients, either in field or on
reaching hospital, should receive prompt IV fluids. Prognosis
depends on the initial fluid replacement. Effective fluid
therapy during first 24 hours gives time for organization
and secondary triage to determine further transfer.
The Baxter Shriners formula using ringer lactate is the
most straight forward and should be followed in all burns
mass causalities. Avoid colloids in first 24 hours. The diuresis
should be maintained at 0.5 ml to 1 ml/per kg/per hour.
Adequate resuscitation is the key to better survival, junior
staff nurses and paramedics can set up IV infusion,
catheterization, administer analgesics and document injury.
In today’s time, digital photography is an efficient way of
rapid documentation.
Initially burns can be covered with just a clean sheet.
Care should be taken to prevent hypothermia, especially in
children. Before any patient is dressed, he should be examined
Table 39.1: Triage criterion and care plan
Triage criterion
Care plan
Minor burns /non-critical Site
Outpatient care, tetanus prophylaxis, dress the wound
< 10%TBSAfor children
< 20%TBSA for adult
Minor burns at critical sites, hand face, perineum
Admit, early operation, special wound care, short hospital stay
20-60% TBSA burned
Admit burn unit, IV fluids, careful monitoring requires
burn trained personnel
Extensive burns >60% TBSA associated with inhalation injury
High mortality, placed in expectant category, pain medication,
trauma or medical illness
psychological support
Inhalation injury, minor burns, associated injuries
Administer oxygen, intubate, ventilate, care of associated injuries
needs to be in burn center

564
Principles and Practice of Burn Care
by burn physician who makes assessment and
documentation of burns. Only then, the patient should be
dressed. Immediate coverage and dressing is a waste of
time of nurses and other junior staff, if not examined in
detail by a burn physician. This is the time when secondary
triage is conducted and if needed patient transferred to
another center.
The protocol for preparing patient for medical evacuation
is as follows:
•
Cannulation of several routes for IV fluids of which one
should be central, followed by chest X-ray to rule out
any complication.
•
Monitoring of urine output
•
Insertion of nasogastric tube
•
Sedation, analgesia, cleansing of wound
•
Tracheal intubations, if required
•
Prevent heat loss.
The only surgical intervention is escharotomy. Early
debridement is not done as the burn surgeon will be busy in
life saving measures for other victims. It should be carried
out only within a burn unit and can be done till 5 days.
Although many units do not start prophylactic antibiotics
routinely, in case of mass casualty, antibiotics are started to
protect the patients from hospital infection. It is also
recommended to start prophylaxis against stress ulcers.
Psychological support and counseling of the victim and
relatives should be given.
DISASTER PLAN IN ACTION
The National Disaster Management Authority published final
State Disaster Management Plan document [SDMP] with
details of guidelines in July 2007.The SDMP document
included various disasters in its list but has not mentioned
burn disaster. It is urgently required that NABI should bring
this anomaly to the notice of NDMA. There should be
planning for mass burn causalities at national level. The
burn physician and burn units are important stakeholders in
the disaster management. National Disaster Management
Guidelines-Medical Preparedness and Mass Casualties
Management (NDMG-MPMCM) Plan should recognize and
include planning for burn mass casualty and recognize burn
units in government and private hospital as national resource.
Any plan for mass burn causality can basically be
considered a generic plan for mass trauma casualties or
any plan for mass casualty can have sub-plan catering to
burn injury.
At district level in case of fire accident leading to burn
injury disaster
What will be done?
How it is to be done?
Who will do it?
The logistics management details to be incorporated and
documented in respective burn disaster plan.
The moot question is how will the disaster plan be
activated and who will trigger its implementation. This will
depend on the first information from the site and as the
police, fire department and district authorities reach they
will provide information to emergency operation center.
Under the guidance of team of expert and leaders trained in
disaster management, the disaster would be declared and
plan shall be implemented with coordination and precision.
In India, either it will be done by district collector or specially
designated disaster management officer.
Establishing emergency operation center (EOC) is a must
and should be done in every district as recommended in
SDMP document. The time bound action plan is must for
creating facilities for environment scanning, intelligence
gathering, operations and logistics management under one
roof for holistic and efficient management of disasters at
the state and district level. Arrangements must be made and
procedures must be laid down for manning the EOC on
24 × 7 × 365 basis. The plan must also cover in detail the
indigenized Incident Command System at the state, district
and local body levels. Only states of Maharashtra and Assam
have established such center with satellite assisted
communication. Without the emergency operation center
which is linked to live voice communication to the entire
stakeholder in disaster management especially hospitals,
ambulance, evacuation services, fire department and police
department, it is not possible to respond to any disaster in a
coordinated manner.
At emergency operation center, data should be available
about hospitals, their capacity and other health facilities.
Some of the district medical officers or some medical
personnel from the local hospital should be trained to act as
field medical officers and act as link and liasoning for
emergency management at the site and evacuation to various
hospitals.
At hospital level, all hospitals should have emergency
incident command system in place, i.e. HEICS and designated
commander should be in constant contact of EOC. Once
there is information about the incident:
ALERT IS DECLARED—liasoning done with various
departments,

Burn Injury Management in Disasters: Indian Perspective
565
Flow chart 39.3: Burns disaster management plan (as suggested by the author)
STANDBY—information confirmed, hospital concerned
consultant put on standby,
EOC contacts hospital incident commander, ambulance and
evacuation agencies,
Disaster management team and burn disaster response
team readied.
Initial Response
Emergency teams sent to site, coordinate triage, transfer of
patient to medical facility, create surge capacity at the
hospital, HEICS activation, discharge patients, postpone
routine surgeries, summon staff, nurses paramedics, alert
pharmacy, blood bank, equipment for emergency care to
be ready.
On Going Management
After initial resuscitation, carry out secondary triage; arrange
Operation Theater for escharotomy and other emergency
operation. Plan for long treatment of the patient requiring
coverage. Schematic plan of burn disaster is given (Flow
chart 39.3):
After action and review: After the burn mass casualty
incident has been managed, a meeting will be arranged of
all the participants and the plan should be reviewed. Otherwise
also, all plans should be reviewed every two years. All the
communication through EOC is transcripted and put on
record. It can be evaluated for coordinating response. The
benefit of such after action review is to bring practical
changes in disaster plan. In the past, after action report of
fire in Hilton Hotel, Las Vegas changed safety and fire
prevention of high rise buildings forever. This resulted in
pressurized fire escapes systems, fire control centers in
high rise hotels, hospitals and other public buildings, fire
sprinkle system, extensive alarm system. etc. Emphasizing
disaster plan makes better disaster prevention.
In India, no analysis of fire disasters is available but
from the judicial inquiries it is known that the worst accidents

566
Principles and Practice of Burn Care
occurred in temporary structures erected without any safety
precaution. We still have not been able to impose safety
standard for the temporary structures erected.
National Burn Mass Casualty
Management System
Training and Community Preparedness Programs: The
government of India (GOI) has also taken up an extensive
program of training for disaster preparedness and response.
The training programs have been designed for the officials
of the government at different levels, NGOs, and elected
representatives of Local Bodies. The Disaster Management
Centers are playing a pivotal role in developing the training
literature and organization of training program. In the next
two to three years, an intensive training schedule will be
drawn up for orienting all the concerned agencies in
different areas of disaster preparedness and response. The
GOI also proposes to take up community disaster
preparedness programs on a pilot basis in different areas
of the state. This program will be implemented through
the selected NGOs for identified disaster spots in the states
and is aimed at building up the mitigation measures into
community life.
Developing leadership is the most crucial and important
aspect and biggest asset a community can build for tackling
mass casualty. This involves knowledge to initiate disaster
plan, provide link between medical care system and incident
response. A team of persons should be trained to provide
disaster-related leadership knowledge and skills and ability
to match hospital and system specific resource, knowledge
of surge plan, resources and techniques in a particular part
of the city or state.
International Applications
In recent years, with rise of international terrorism which
is trans borders, it has been noticed that there has been
more international cooperation in disaster management.
Especially in case of Bali bombings, large patients were
shifted to Australia and treated there. In the past also, United
States of America, United Kingdom, France, Israel and Cuba
have sent their teams for international medical relief. Sending
such teams help in tiding away the disaster response need
but also bring exchange of new ideas, learning, teaching
and sometimes upgrading the host countries medical
systems. National Academy of Burns-India along with
Government of India should form such burn disaster
international relief teams. These teams should be self
sufficient, should carry their own bulk supplies and they
should not be burden on host country. The required
equipment should be stockpiled and kept ready to be retrieved
and airlifted with the team on short notice. Such team has
to be in state of preparedness
LEGAL FRAME WORK
Although the disaster management has had paradigm shift
with enactment of national Disaster Management Act, 2005
by Government of India which provides for the creation of
a policy, legal and institutional framework, backed by
effective statutory and financial support, the details of the
following relevant points remain to be worked out by states.
Authority to Declare Disaster
•
Induction and triggering disaster management.
•
Legal responsibility to treat.
•
To admit and treat without questioning financial
implications.
•
Liability of health department not to be held liable for
any criminal and civil suits whosoever participates in
disaster management.
•
Power to quarantine or restrict movement.
•
Compelling provider to participate in disaster
management.
•
Stream lined financial issues with provider and the
victim.
As the states develop their disaster management plans and
enact it as law under DM Act 2005, most of these issues
will be resolved.
Principles of disaster management: For preparing any
burns disaster plan one should follow the principles. The
disaster management and the principles are as follows:
•
Prevention
•
Preparedness
•
Disaster profiles
•
Disaster patterns
•
Planning and preparation for effective multi-disciplinary
response
•
Mobilization of multi-sectoral manpower resource
•
Risk assessment
•
Post-emergency phase
•
Reconstructive phase
•
Community and institutional involvement

Burn Injury Management in Disasters: Indian Perspective
567
CONCLUSION
India is developing its national disaster management.
National disaster management Act, 2005 has been
enacted.
It is mandatory for the states to enact their state disaster
management plans.
National Disaster Management Authority (NDMA) and
National Institute for Disaster Management (NIDM) are the
key bodies for disaster management in India.
There is a need to include burn disaster in the plans.
Characteristics of the pathological conditions affecting
burn victims, respiratory complications and associated poly
trauma in a burn disaster are different from other type of
disasters.
The burn disaster should be addressed systematically.
Legislation of disaster management should include burn
disaster.
NABI should become a stakeholder in disaster
management plans. It has capacity to be the component in
national disaster readiness for mass burn incidents.
EOCs at district level are the basic building blocks of
disaster management.
All hospitals should develop their HEICS program and
implement and rehearse it regularly.
Recommendation for initial management, triage and
further treatment in burn units must be developed for our
country.
Physician at all levels must be trained in triage and initial
management of burns.
Community at large and all stakeholders should be trained
in disaster management.
Awareness programs should be conducted regularly for
community involvement; every citizen should have ability
to deal with emergency.
This article is based on publications of Government of India,
viz.,
1. Disaster Management Act, 2005 document,
2. State disaster management plan recommendations of
National Disaster Management Authority published by
Government of India, July 2007; and
3. Disaster Management plan, State of Maharashtra and
text and diagrams from the same have been used.
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Appendices
569
Appendices
APPENDIX 1.1:
COMPOSITION OF COMMON IV FLUIDS
Crystalloids
Name
Na+
K+
Cl–
HCO3
–
Misc
CHO(g/l)
Pr (g/l)
MJ/l
Osmolal
pH
N. Saline
154
0
154
0
0
0
0
0
308
5.0
Glucose 5 %
0
0
0
0
0
50
0
0.84
280
4.0
Ringer Lactate
131
5
112
29
Mg 1Ca 1
0
0
0.04
280
6.5
Lactate
28 mM
NaHCO3
1000
0
0
1000
0
0
0
0
2000
8.0
Glucose 4%
31
0
31
0
0
40
0
–
284
4
Saline 0.18%
Glucose 5%
77
0
77
0
0
50
0
–
431
4
Saline 0.45%
Concentration of ions given as mmol/L.
Colloids
Name
Na+
K+
Cl–
Misc
CHO (g/l) Pr (g/l)
MJ/l
pH
Onc. Pres.
t 1/2
Human Albumin
4% sol
150
2
120
-
0
19
40
7.4
275
12 hrs
Hemmaccel
145
5.1
145
Ca 6.3
0
35
0
7.4
370
5 hrs
(succinylated
Gelatin 40 g
gelatin)
HAES
154
0
154
Starch 60 g
0
0
0
5.5
310
17 days
Concentration of ions given as mmol/L.
t1/2 half life in plasma

570
Principles and Practice of Burn Care
APPENDIX 1.2:
BODY SURFACE AREA
Dubois nomogram for body surface area
Nomogram for body surface area for children
Approximate areas of the body surface in children at various ages
Age (yr)
Area (m2)
Substance
Traditional units
SI units
Alanine aminotransferase (SGPT)
0-35 U/L
0-0.58 µKat/L
Albumin
4-6 g/dl
40-60 g/L
Alkaline phosphatase
F—30-100 U/L
0.5-1.67 µKat/L
M—45-115 U/L
0.75-1.92 µKat/L
Amylase
0-130 U/L
0-2.17 µ Kat/L
Aspartate aminotransferase (SGOT)
0-35 U/L
0-0.58 µ Kat/L
Bicarbonate
22-26 mEq/L
22-26 mmol/L
Bilirubin — total
0.1-1.0 mg/dl
2-18 µmol/
— conjugated
Blood urea nitrogen(BUN)
8-18 mg/dl
3-6.5 mmol/L
Calcium — total
8.5-10.5 mg/dl
2.2-2.6 mmol/L
— ionized
2.2-2.3 mEq/L
1.10-1.15 mmol/L
Chloride
95-105 mEq/L
95-105 mmol/L
Creatinine
0.6-1.5 mg/dl
0.05-0.13 mmol/L
Glucose — fasting
70-100 mg/dl
3.9-6.1 mmol/L
Magnesium
1.8-3.0 mg/dl
0.8-1.2 mmol/L
Osmolality
280-296 mOsm/kg
280-296 mmol/L
Phosphate
2.5-5 mg/dl
0.80-1.60 mmol/L
Potassium
3.5-5.0 mEq/L
3.5-5.0 mmol/L
Sodium
135-147 mEq/L
135-147 mmol/L
Total protein
6-8 g/dl
60-80 g/L
APPENDIX 1.3:
NORMAL BIOCHEMICAL VALUES

Appendices
571
Body build
Average blood volume (ml/kg)
Males
Females
Thin
65
60
Normal
70
65
Muscular
75
70
Obese
60
55
APPENDIX 1.4:
BODY BUILD AND BLOOD
VOLUME IN ADULTS
APPENDIX 1.5:
FLUID COMPOSITION OF
BODY COMPARTMENTS
Estimates of Blood Volume
Infant
90 ml/kg body weight
Child
80 ml/kg body weight
Adult Male
70 ml/kg body weight
Adult Female
60 ml/kg body weight
Total Water Content
Adult Male
60 % body weight
Adult Female
55 % body weight
Extracellular Fluid Volume
35 % total water content
Intracellular Fluid Volume
65 % total water content
APPENDIX 1.6:
COMPOSITION OF DIFFERENT
BODY FLUIDS
Parameter
Males
Females
Total body water
600 ml/kg
500 ml/kg
Interstitial fluid
160 ml/kg
160 ml/kg
Blood volume
70 ml/kg
65 ml/kg
Erythrocyte volume
33 ml/kg
27 ml/kg
Plasma volume
37 ml/kg
38 ml/kg
Hematocrit
47% (mean)
42% (mean)
40-54%
37-47%
APPENDIX 1.7:
NORMAL VALUES FOR
COAGULATION TESTS
Partial thromboplastin time
35-45s
Prothrombin time
12-14s
Bleeding time (platelet function)
2-9 min
Plasma fibrinogen
1.5-4.0 g/L
Fibrin degradation products(FDPS)
<10 mg/L

572
Principles and Practice of Burn Care
APPENDIX 2.1
AVAILABLE ENTERAL
FORMULAE
Presently a wide variety of ready to use commercially
prepared diets are available in the market to meet the
requirements. However, ready to use feeds are expensive
and in our country we still prefer to use blended home made
diets.
Example of Home Made Blended Feed
1000 ml milk/buttermilk + 4 eggs + 4 bananas +10
tablespoons of sugar or honey
Final composition of the above is approximately 1700 ml
and it provides 1 Kcal/ml of energy, 60 gm of protein and
350 gm of carbohydrate.
Commercially Available Enteral Formulae
Include
•
Standard formulae (e.g. Fresubin) provide 1kcal /ml.
•
Special formulae (Nutrilite) have high essential amino
acids content.
•
Fiber enriched formulae (Acti-base)
•
High lipid content formulae (Pulmocare)
•
Glutamine enriched formulae
Food
Dose
Nutritional Value
product
Fresubin
50 gm + 180 ml water
E-220 kcal
Protein – 8.3 gm
Fat – 7.4 gm
1 kcal/ml
Threptin
Approx. 5 gm
Protein – 1.5 gm
Diskettes
Carbohydrate –
Fat – 0.7 gm
22 Calories/Diskette
Nutrilite
10 gm
Protein – 8 gm
1 scoop
Carbohydrate – 0.5 gm
Fat – 0.3 gm
Calories 36 kcal
Acti-base
2 scoops
Protein – 16.5 gm
Carbohydrate 15 gms
Fat 0.7 gm
Calories – 132 kcal
GRD
100 gm/2 tsf =30 gm
Protein – 18.5 gm
Carbohydrate – 63 gm
Calories – 425 kcal/
100 gm
Table 2.1A: Commercially available protein rich powder with
nutritive values
Table 2.1B: Commercially available amino acids and lipids
Trade name
Dosage
Protein
Non-protein calories
Alamine –N
200 ml
6 gm
24 kcal
over 2-3 hr
Alamine –SE (in patients
20 ml
1.64 gm
6.5 kcal
with oliguric renal failure)
Alamine –SN
20 to 500 ml
2 gm
80 kcal
Amino Drip
200 to 500 ml
7.5 gm/100 ml
30 kcal /100 ml
Hermin
200 to 800 ml
100% essential amino acids
500 ml 10% = 450 kcal
Lipofundin
100 ml to 500 ml
20% = 900 kcal
(5 to10 %)
10 to 20 ml /kg/day start with
15 to 20 drops /min. after 15
minutes increase to 45 drops/min.

Appendices
573
Average
weight
protein
Fat
Carbohydrate
Calories
portion
Beverages
Coffee: Cows milk ,sugar 2 tsf
1 Cup
200
1.1
1.1
11.4
60
Lemonade: Fresh lime juice 2 tbl. Sp.,
1 Glass
240
-
-
17.4
73
sugar 3 teaspoon
Tea : Cow’s milk 2 tablespoons
1 Cup
200
0.9
1.1
11.4
60
sugar 2 teaspoons
Cereals and cereal food
Cornflakes
1 Cup
25
2.1
0.1
2.1
95
Jowar (sorgum vulgare cholam)
1 small
45
3.1
0.6
22.2
106
Chapatti
Maize 30 gm flour
1 Chapatti
45
3.3
1.1
19.8
102
Ragi 30 gm flour
1 Chapatti
45
2.1
0.4
21.6
98
Rice, milled, boiled (3 tbl. spn .dry)
1 Cup
-
2.9
0.1
30.2
138
Wheat Bread
1 Slice
30
2.3
0.5
15
75
Wheat ‘chapati’ (15 gm flour)
1 thin
-
1.2
0.1
8
40
Wheat ‘Parantha’ 60 gm and fat
1
-
4.8
10.4
36
256
2 teaspoons
Milk and Milk Products
Buttermilk, Buffalo’s (curd 1 cup
1 Cup
200
2.7
4.6
2.1
62
making 3 cups of butter milk )
Cheese, cheddar
1Piece
28
7
9
0.6
111
Cheese cottage
1 round
28
5.5
0.1
0.6
27
tablespoon
Cream light
1 tablespoon
30
0.8
5.4
1.2
56
Curd, buffalo milk
1Cup
200
8
14
6.3
182
Ice cream
1 helping
100
4.1
11.3
19.8
196
Milk Buffalo’s
1Cup
200
8
14
6.3
182
Milk Buffalo’s skimmed
1Cup
200
8.4
0.2
10.8
78
Milk Cow’s
1Cup
200
7
9
9.6
160
Milk Cow’s skimmed
1Cup
200
7.2
0.2
10
70
Milk condensed sweetened
1 tablespoon
20
1.5
1.7
10.1
62
Milk Goat’s
half cup
100
3.3
4.1
4.7
75
Milk whole Powdered
1 tablespoon
7
1.9
1.9
2.7
35
PULSES, DRIED PEAS AND BEANS
Bengal Gram (urad dal)
1Cup cooked thin dal
200
7
2.3
14 105
Black Gram (urad dal)
1Cup cooked thin dal
200
7
2.3
14 105
Green Gram (murg dal)
1Cup cooked
200
7
2.3
14
105
Field bean (val dal )
half Cup
100
6
0.4
17.3
92
Lentil (masur dal )
100
22.9
11.4
58.1
340
Peas Dried
Red Gram (tur dal)
Beans baked
Peas Roasted
APPENDIX 2.2: NUTRITIVE VALUE OF INDIAN
FOODS

574
Principles and Practice of Burn Care
Table 2.3A: Diet chart
Main food
Weight and
Calories
Protein
Group
Measures
Pre-breakfast
Tea with sugar
125 ml
40
+
4 Marie biscuits
4
50
Breakfast
Milk + 2 tsf sugar
200 ml + 30 gm + 30 gm
200 + 120
10 + 3 gm
+2 tsf Proteinex
Porridge/Cornflakes
2 Katori
410
2 gm
Dalia
Stuffed Parantha
90 gm + 40 gm
210 + 100
20 gm + 2 gm
Bread 2 slices +
40 gm
100
10 gm
2 egg
Pre-lunch
Sprout or Roasted Chana
1 Katori
140
6 gm
Cheese
2 Cubes
100
10 gm
Milk + 2 tsf
200 ml
320
13 gm
Proteinex+ 2 tsf
Sugar
Lunch
Cereal
Chappati 4 medium size
600
120 gm +2 tsf Ghee(30 gm)
Leafy Vegetables
2 Cups
40
Dal or whole Pulses/Non Veg.
3/4 Katori cooked
100
6 gm
Curd/ Raita /Butter Milk
1/2 Cup
40
Fruit
Banana (big)
80
Evening Snacks
Milk + 2 tsf
200 ml + 4-5 Marie Biscuits
320
13 gm
Proteinex + 2 tsf
Sugar
Cereal
Dhokla /Veg. Sandwitch/
140
Sprouts/Roasted chana
Predinner
Chicken soup
1 Cup 200 ml
185
10 gm
Corn soup (sweet)
1 Cup
120
Dal soup
1 Cup
169
6 gm
Dinner
Cereal
Chappati (4 med. Size)
600
Leafy Vegetable
1 Katori (30 ml )
50
Dal or Pulses
1 Katori (cooked)
100
6 gm
Curd
½ Cup
40
Desserts
Rasgulla or
1 (150 gm)
140
Gulab Jamun or
25 gm
200
Laddo or
30 gm
160
Mango Juice
200 ml (Big Glass)
150
Use 4 Tsf Ghee Per Day
Total Calories = 4,000 Kcal; Total Protein = 117 gm
APPENDIX 2.3: DIET CHART FOR BURN
PATIENTS AND THEIR NUTRITIVE VALUE
(TABLE 2.3A)
Calculations: 3,000 to 4,000 kcal + 180 gm of Protein can
be given by oral route. According to Currerie Formula:
For a 40% Burns
50 kg weight}- Calories required = 20 × body weight + 70 ×
% of burns
Calories = 20 × 50 + 70 × 40 = 3800 kcal
Protein = 1 gm/kg + 3 gm/% of burn
Protein = 50 + 3 × 40 = 170 gm

Appendices
575
APPENDIX 2.4: TOTAL PARENTERAL NUTRITION
TPN can be given as separate components like amino drip,
intra lipid, 10% dextrose or as premixed multi-component
solutions like Clinomel, which are now available and have
reduced the potential for error and metabolic aberration.
Maximum rate of dextrose administration should be 4-6
mg/kg/min to avoid the risk of hyperglycemia.
If carbohydrate is given as the only source of energy, it
can lead to:
•
Deficiency of essential fatty acids
•
Deficiency of fat soluble vitamins
•
Excess CO2 load
•
Hepatic steatosis
•
Increases osmolarity of solution
Instruction charts should be maintained stating the following
details of parenteral nutrition.
•
Total energy calculated on body weight basis.
•
Substrate distribution (volume of carbohydrate, fat and
protein)
•
Fluid volume.
•
Rate of delivery.
•
Hang time.
•
Total time frame.
•
Steps to be taken in case of accidental change in rate of
delivery.
It is said that to prevent the complications of parenteral
feeding, like over feeding of intravenous nutrients which
may lead to hepatic disorders, fluid retention and metabolic
derangements, the required volume for the parenteral
nutrition is determined by the rate of substrate utilization as
opposed to a predetermined energy goal, as demand of
energy may reach to 50 kcal/kg/day. It is important to keep
a rational balance and not overload the patient with huge
amounts of energy.
The maximum oxidation of glucose in liver is when
given at a rate of 4-6 mg/kg/min. If given beyond this rate,
it is not assimilated but deposited as fat beneath the skin.
Proteins at 2.5-4 gm/kg can be given, increasing
gradually to the desired goal.
Fat at 20% intralipid is given but not during acute phase
of shock. Starting with 0.5 gm/kg/hour, the maximum rate
of 0.119gm/kg/hour or 1.0 to 1.5 gm/kg/day should not be
exceeded.
Intralipid administration should not exceed more than
3.6 gm/kg/day. Calculate daily volume requirement on
the basis of;
•
All on-going losses, including insensible loss
•
Input-output chart
•
Alternatively, 30 to 40 ml/kg body weight
•
Caution in patients with renal dysfunction and congestive
heart failure
For infants and children < 20 kg =1.7 ml/kg/hour
For children> 20 kg =1.5 ml/kg/hour.
This is started at 60 ml/hr and increased to 80 to 100
ml/hr after 4 to 6 hours. PN should not be started out of
hours (evenings and weekends).Lipid emulsions when given
alone should be completely infused within 12 hours of
hanging. Lipids when administered as total nutrient admixture
can be hung for 24 hours.
If parenteral nutrition is interrupted due to any reason,
clear instructions should be stated to administer 10% dextrose
solution at the same rate to prevent sudden hypoglycemia
caused by high endogenous insulin. Complications of
intravenous hyperalimentation are greater than with enteral
route.
APPENDIX 2.5:
STANDARD PARENTERAL
SOLUTION
Parenteral nutrition may be delivered either through all in
one system like OliClinomel which is a preferred way of
administering parenteral nutrition in our unit where all
macronutrients and micronutrients required for 24 hours
are infused from one bag or through multiple bottles. There
are fewer chances of infection and metabolic aberrations in
using single bag system.
Oliclinomel
Oliclinomel N4-550E, emulsion for infusion.
Qualitative and Quantitative Composition is given in Tables
2.5A and 2.5B.
This medicinal product is presented in the form of 3
compartment bag.
It is available in 4 different presentations and volumes.
Table 2.5A: Qualitative and quantitative composition of oliclinomel
Compartment
1000 ml
1500 ml
2000 ml
2500 ml
Lipid emulsion
200 ml
300 ml
400 ml
500 ml
Amino acid
400 ml
600 ml
800 ml
1000 ml
solution
Glucose solution 400 ml
600 ml
800 ml
1000 ml

576
Principles and Practice of Burn Care
Table 2.5B: After the contents of the three compartments have
been mixed, the final mixture for each of the bag
Per bag
1 Liters
1.5 Liters
2 Liters
2.5 Liters
Nitrogen (g)
3.6
5.4
7.3
9.1
Amino acids (g)
22
33
44
55
Total calories (kcal)
610
910
1215
1520
Non-protein calories
520
780
1040
1300
(kcal)
Glucose calories
320
480
640
800
(kcal)
Lipid calories (kcal)
200
300
400
500
Non-protein calories/
nitrogen
Ratio (kcal /gm N)
144
144
144
144
Sodium (mmol)
21
32
42
53
Potassium (mmol)
16
24
32
40
Magnesium (mmol)
2.2
3.3
4.4
5.5
Calcium (mmol)
2
3
4
5
Phosphate (mmol)
8.5
13
17
21
Acetate (mmol)
30
46
61
76
Chloride (mmol)
33
50
66
83
pH
6
6
6
6
Osmolarity (mmol/L)
750
750
750
750
The final mixture allows parenteral nutrition for adults
and children above 2 years of age when oral or enteral
nutrition is not possible, insufficient or contraindicated.
Dosage depends on metabolic requirements, energy
expenditure and the patient’s clinical condition.
Maximum Daily Dose in Adults
The maximum daily dose is 40 ml/kg body weight (equivalent
to 0.88 g of amino acids, 3.2 g of glucose and 0.8 g of
lipids per kg ) i.e. 2800 ml of the emulsion for a patient
weighing 70 kg.
Maximum Daily Dose in Children Above 2 Years
The maximum daily dose is 100 ml/kg body weight
(equivalent to 2.2 g of amino acids, 8 g of glucose and 2 g
of lipids per kg body weight)
As a general rule, do not exceed doses of 3 g/kg/day of
amino acids and/ or 17g/kg/day of glucose and/or 3g/kg/
day of lipids, except in spacial cases. The dosage is based
on fluid intake and daily nitrogen requirements.
Special Warnings
Water and electrolyte equilibration and metabolic disorders
must be corrected before starting the infusion. This product
does not contain vitamins or trace elements. They should
be supplemented
APPENDIX 2.6: NUTRITIONAL ASSESSMENT
CHART (TABLE 2.6A)
Stepwise Calculation of Nutritional
Requirement
Surgeons and residents involved in management of burns
should learn to prescribe a nutritional regimen in a methodic
and scientific manner as follows:
1. Before starting nutritional support, patients with shock
should be adequately resuscitated and gross fluid and
electrolyte imbalance corrected. Mild degree of fluid and
electrolyte imbalance can be corrected with ongoing
nutritional support.
2. Decide on the route of administration for nutrition, plan
the oral/enteral/or parenteral nutrition or partial parenteral
nutrition.
3. Calculate the energy requirements of burn patients
according to currerie formula depending on the size of
burn wound and age of the patient
4. These formula or equation for calorie estimation often
overestimates the calorie requirements.
5. To avoid this and simplify it, one can easily calculate the
calorie protein needs according to appropriate stress level
taking the severity of disease into consideration.
6. Calories are derived from three major substrates—
Carbohydrates, fats, and proteins. By and large 50% of
calories are derived from carbohydrates, 30% from fats
and 20% from proteins. In critically ill patients, certain
adjustments are required as mentioned earlier.
7. After finalizing the total calorie and substrate
requirements, the total permissible liquid intake has to
be calculated. Normal recommendation is 30-40 ml/kg/
day. However, liquid intake has to be adjusted in specific
conditions such as renal and cardiac failure, where
volume load needs to be restricted. Consequently; total
calories will have to be given in restricted volume of
fluid. In patients on total parenteral nutrition, this
becomes a challenge and one will have to resort to using
more lipid emulsions as they give higher calories on
weight to weight basis.
8. Let us now practically work out a stepwise prescription,
taking an actual case scenario, a male patient aged 40
years, weighing 50 kg with 20% burns.

Appendices
577
Table 2.6A: Nutritional assessment chart
Name of Patient
Age/Sex
Height Weight
Ideal Weight
Date of Burn.
Date of Arrival
Total Body Surface Burn.
% Full thickness
Estimated Energy Requirement
Kcal/Day
Estimated Protein Requirement
Gms/Day
Kcal
Oral
Enteral
Parenteral
Protein
Oral
Enteral
Parenteral
Na+/K+
Glucose
BUN
Step 1
Energy = (25 × wt in kg) + (20 × % burns) E = (25 × 50)
+ (20 × 20)
E = 1650 kcal
Step 2
Protein requirement in 24 hours
2 gm/kg body wt.
Protein = 2 × 50 = 100 gm
Protein calories = 100 × 4 =400 kcal
So non-protein Energy (NPE) = 1650 – 400 = 1250 kcal
Energy values Protein = 4 kcal /gm
Carbohydrate = 4 kcal/gm
Fat = 9 kcal/gm
Step 3
For all age groups give 40 to 50% of non-protein calories
as fat, 50 to 60% as carbohydrate.
50% of 1250 = 625 kcal
Fat required = 625/9 = 70 gm
Carbohydrate required = 625 /4 = 156 gm
Step 4
Daily requirement in 50 kg wt. patient with 20% burn is:
Protein = 100 gm
Carbohydrate = 156 gm
Fat = 70 gm
1 liter of 5% dextrose = 50 gm of monohydrate glucose =
200 kcal
6.25 gm of protein = 1 gm of body nitrogen

578
Principles and Practice of Burn Care
Step 5
Calculate fluid Intake in 24 hours
Average requirement in an adult male is 40 ml /kg/day
i.e. 40 × 50 = 2000 ml/day
Step 6
Now prepare standard nutrition (Parenteral/oral/enteral) for
2000 ml
If more than 180 gm of carbohydrate is given/day
frequent monitoring of blood glucose is required and insulin
may be necessary.
100 gm protein = 1000 ml of 10% amino acids
150 gm of carbohydrate = 750 ml of 20% dextrose
70 gm of lipids = 350 ml of 20% lipofundin
Total volume = 2100 ml giving 1650 calories
The above composition can be conveniently delivered as an
All-in-one solution which is commercially available as
Clinomel or as multiple bottles available as amino drip,
lipofundin and dextrose
Step 7
If the above patient develops renal failure and his protein
intake has to be decreased to 40 gm of proteins and 1000
ml of fluid intake /day
Table 2.6B: Sliding scale for insulin dose management
Finger stick glucose
Amount of regular
Concentration (mg/dl)
Human insulin (units)
Less than 70
0
71 to 125
0
126 to 150
2
151 to 175
4
176 to 200
6
201 to 225
8
226 to 250
10
251 to 275
12
276 to 300
14
more than 300
16
40 gm of protein = 400 ml of 10 % aminodrip
150 gm carbohydrate = 300 ml of 50 % dextrose
70 gm lipids = 250 ml of 30% lipids
Final volume = 950 ml giving 1470 calories
It can be given as 50% glucose solution, 30% lipid solution
and 10% amino acid solution
Diabetics or patients with glucose intolerance require close
monitoring of blood glucose levels and need correction.
For them, reduce glucose as energy substrate and instead
use lipid regimens.
Insulin may be given according to revised sliding scale
by Dickerson (Table 2.6B).

Appendices
579
NUTRITIONAL VALUES
NUTRITION READY RECKONER
These are average values for standard recipes found in most books
Calories Proteins Fats
Carbo- Fiber
Calcium Iron
Caro-
Retinol Vit B1
Vit B2
Niacin
Vit C
Serving
(Kcal)
(g)
(g)
hydrates (g)
(mg)
(mg)
tene
(mcg)
(mg)
(mg)
(mg)
(mg)
Portion
(g)
(mcg)
BEVERAGES
Hot Tea
34
0.6
1.0
5.7
0.0
31.0
0.0
0.0
7.00
0.01
0.01
0.0
0
1 Tea Cup
Instant Coffee
149
1.0
13.3
6.3
0.0
31.0
0.0
0.0
7.00
0.01
0.01
0.0
0
1 Tea Cup
Cold Coffee
279
3.9
17.0
27.7
0.0
144.0
0.3
487.0
183.00 0.06
0.23
0.1
2
1 Tall Glass
(with Cream)
Banana Milk
228
6.2
7.5
33.8
0.0
223.0
0.5
40.0
101.00 0.11
0.37
0.4
7
1 Tall Glass
Shake
Mango Milk
237
6.2
7.7
35.6
0.8
227.0
1.3
2067.0 608.00 0.15
0.41
9.0
16
1 Tall Glass
Shake
Lemonade
107
0.3
0.3
25.7
0.5
21.0
0.1
0.0
0.00
0.01
0.00
0.0
12
1 Glass
BREAKFAST
CEREALS
Cracked Wheat
292
10.0
10.4
39.7
2.5
296.0
1.5
152.0
39.00
1.29
0.49
1.3
5
1 Bowl
Porridge
Semonlina
293
9.8
10.2
40.4
0.0
291.0
0.8
139.0
36.00
1.24
0.47
0.6
5
1 Bowl
Porridge
Vermicelli
294
9.4
10.2
41.1
2.5
292.0
0.9
139.0
36.00
1.24
0.47
0.6
5
1 Bowl
Porridge
Oat Meal
217
6.6
6.6
32.8
2.0
154.0
1.0
70.0
18.00
0.80
0.26
0.3
2
1 Bowl
Porridge
Cornflakes with
291
9.8
10.8
38.7
1.2
290.0
0.9
157.0
41.00
1.28
0.48
0.6
5
1 Bowl
Milk
Semolina Upma
147
2.3
7.7
17.1
9.9
11.0
0.5
1.0
0.00
0.04
0.01
0.4
2
1 Bowl
Vermicilli Upma
296
4.0
15.2
35.7
5.4
24.0
1.2
2.0
1.00
0.10
0.03
0.9
5
1 Bowl
Vegetable Upma
192
4.4
9.7
21.7
1.5
22.0
0.9
107.0
27.00
0.20
0.02
1.6
4
1 Bowl
Poha
158
2.8
7.3
20.2
1.5
10.0
4.2
6.0
1.00
0.10
0.02
2.0
3
1 Bowl
Vegetable with
202
4.9
9.3
24.7
2.1
21.0
4.6
111.0
28.00
0.18
0.03
3.1
5
1 Bowl
Poha
EGGS
Boiled Egg
87
6.7
6.7
0.0
0.0
25.0
0.7
300.0
180.00 0.05
0.20
0.1
0
1 Egg
Poached Egg
87
6.7
6.7
0.0
0.0
25.0
0.7
300.0
180.00 0.05
0.20
0.1
0
1 Egg
Fried Egg
160
6.7
14.8
0.0
0.0
25.0
0.7
620.0
260.00 0.05
0.20
0.1
0
1 Egg
Scrambled Egg
172
6.7
15.8
0.8
0.0
57.0
0.7
620.0
267.00 0.06
0.22
0.1
0
1 Egg
Baked Egg
124
6.7
10.8
0.0
0.0
25.0
0.7
460.0
220.0
0.05
0.20
0.1
0
1 Egg
Fluffy Omelette
160
6.7
14.8
0.0
0.0
25.0
0.7
620.0
260.00 0.05
0.20
0.1
0
1 Egg
Cheese and
308
12.9
27.1
3.0
0.0
182.0
1.3
780.0
373.00 0.09
0.42
1.5
1
1 Egg
Mushroom
Omelette
SOUPS
Minestrone Soup
90
1.4
5.2
9.4
1.2
43.0
0.7
491.0
123.00 0.07
0.03
0.5
17
1 Bowl
Chicken Sweet
322
25.5
13.5
24.6
6.0
23.0
2.6
10.7.0
93.00
0.21
0.34
8.6
6
1 Bowl
Corn Soup
French Onion
208
4.8
11.6
21.1
2.4
102.0
0.8
321.0
110.00 0.08
0.05
0.6
8
1 Bowl
Soup
Tomato Soup
82
2.1
4.5
8.3
2.3
101.0
1.3
862.0
216.00 0.25
0.21
0.8
55
1 Bowl
Green Pea Soup
186
9.0
6.4
23.1
2.2
70.0
1.9
375.0
109.00 0.28
0.08
1.1
11
1 Bowl
Spinach Soup
561
3.9
8.9
116.2
5.9
81.0
1.5
5902.0 1475.000.06
0.27
0.08
29
1 Bowl
Contd.

580
Principles and Practice of Burn Care
Mixed Vegetable
146
3.3
9.2
12.5
1.4
124.0
0.9
779.0
225.0
0.11
0.16
0.6
23
1 Bowl
Soup
Cream with
245
5.4
16.6
18.5
2.3
180.0
1.5
984.0
287.00 0.32
0.25
1.0
45
1 Bowl
Tomato Soup
Cream with
307
8.5
23.2
16.0
5.1
200.0
2.2
6214.0 1644.0 0.20
0.52
0.9
32
1 Bowl
Spinach Soup
Cream with
250
4.6
16.2
21.5
2.0
172.0
1.4
1935.0 531.00 0.17
0.17
0.9
6
1 Bowl
Carrot Soup
Cream of Pea
342
12.4
18.2
32.2
2.6
132.0
2.4
590.0
188.00 0.44
0.17
1.4
15
1 Bowl
Soup
Cream with
282
5.4
13.1
35.7
3.1
118.0
1.1
415.0
144.00 0.24
0.17
1.6
21
1 Bowl
Potato Soup
Cream with
263
7.5
13.4
28.0
3.2
179.0
2.0
1160.0 331.00 0.33
0.24
1.5
45
1 Bowl
Mixed Vegetable
Soup
Cream with
308
6.6
22.4
19.9
0.7
136.0
1.5
554.0
189.00 0.13
0.41
2.9
6
1 Bowl
Mushroom Soup
Hot and Sour
181
11.2
9.3
13.2
1.6
65.0
2.8
86.0
22.00
0.22
0.25
23
6
1 Bowl
Soup
CEREALS
Chapati
273
9.7
1.4
55.5
5.6
38.0
3.9
23.0
5.00
0.39
0.14
3.40
0
3 or 4
Plain Parantha
363
9.7
11.4
55.5
5.6
38.0
3.9
23.0
6.00
0.39
0.14
3.40
0
3 Medium
Potato Stuffed
632
11.2
31.5
75.8
7.9
56.0
4.4
42.0
10.00
0.49
0.15
4.50
16
3 Medium
Parantha
Pea Parantha
693
20.7
31.5
75.8
7.9
78.0
6.3
148.0
37.00
0.78
0.15
4.70
16
3 Medium
Cauliflower
577
12.0
31.7
60.9
7.1
74.0
5.0
47.0
12.00
0.44
0.22
4.30
47
3 Medium
Parantha
Radish Parantha
574
10.8
31.5
61.8
8.2
90.0
4.5
27.0
7.00
0.48
0.16
4.10
20
3 Medium
Daal Parantha
665
16.2
33.1
75.6
9.0
65.0
5.6
62.0
15.00
0.55
0.19
4.20
3
3 Medium
Sprouted Dal
727
22.1
32.0
87.6
10.2
85.0
6.0
48.0
12.00
0.64
0.24
4.70
2
3 Medium
Parantha
Paneer Parantha
713
20.9
43.9
58.5
5.9
173.0
4.0
243.0
61.00
0.45
0.15
3.50
4
3 Medium
Onion-Green
594
10.9
31.5
66.6
7.1
85.0
4.5
23.0
6.00
0.57
0.15
3.80
11
3 Medium
Chilli Parantha
Keema Parantha
712
24.8
42.1
58.4
5.9
169.0
6.2
25.0
13.00
0.55
0.25
9.00
3
3 Medium
Methi Parantha
652
14.2
32.4
75.8
8.1
293.0
7.2
1230.0 303.00 0.52
0.32
4.50
0
3 Medium
Pooris
375
9.2
12.1
57.4
4.0
28.0
3.0
42.0
11.00
0.24
0.10
2.70
0
3 Medium
(10 g oil
absorbed)
Daal Stuffed
427
12.8
12.3
66.3
51.5
5.0
3.6
47.0
12.00
0.31
0.13
3.00
0
4 or 5
Pooris
Palak Pooris
388
10.2
12.4
58.8
64.9
6.0
3.6
2832.0 708.00 0.26
0.23
2.9
14
4 or 5
Besan Pooris
380
11.2
13.0
54.6
5.5
35.0
3.6
62.0
16.00
0.32
0.12
2.7
0
4 or 5
Pea Pooris
431
13.6
12.1
66.9
5.0
40.0
3.9
91.0
23.00
0.39
0.10
3.2
5
4 or 5
Pea Kachori
215
6.9
7.4
30.2
1.8
17.0
1.6
49.0
13.00
0.16
0.03
1.1
5
2
(10 g oil
absorbed)
Khasta Kachori
441
11.4
18.9
56.3
3.2
45.0
2.4
163.0
41.00
0.16
0.8
1.8
0
2
(10 g oil
absorbed)
Naan
200
6.7
2.1
38.5
1.5
60.0
1.4
31.0
9.00
0.19
0.10
1.2
1
1
Bhatura
176
5.6
3.8
29.9
1.2
28.0
1.2
51.0
27.00
0.06
0.07
0.1
0
2 or 3
Boiled Rice
277
6.0
0.8
61.4
3.6
8.00
2.6
2.0
0.40
0.17
0.13
3.1
0
1 Full plate
Calories Proteins Fats
Carbo- Fiber
Calcium Iron
Caro-
Retinol Vit B1
Vit B2
Niacin
Vit C
Serving
(Kcal)
(g)
(g)
hydrates (g)
(mg)
(mg)
tene
(mcg)
(mg)
(mg)
(mg)
(mg)
Portion
(g)
(mcg)
Contd.
Contd.

Appendices
581
Curd Rice
484
15.1
12.5
77.8
5.3
253.0
3.8
66.0
26.00
0.33
0.41
3.7
2
1 Full plate
Zeera Pulao
400
8.2
10.5
68.1
4.4
25.00
2.9
78.0
45.00
0.22
0.18
3.5
6
1 Full plate
Mixed Vegetable
523
17.6
9.0
92.9
7.2
71.0
5.2
126.0
32.00
0.60
0.15
4.6
21
1 Full plate
Pulao
Pea Pulao
510
12.1
9.1
94.8
8.1
108.0
4.6
1033.0 258.00 0.44
0.17
4.8
28
1 Full plate
Channa Daal &
529
15.1
10.1
94.3
8.5
102.0
5.3
1014.0 254.00 0.47
0.19
4.6
14
1 Full plate
Vegetable Pulao
Black Channa
464
10.9
10.2
82.1
7.5
82.00
4.0
49.0
11.00
0.28
0.17
4.1
6
1 Full plate
Pulao
Mushroom Pulao
411
9.7
9.7
71.2
4.3
38.00
4.4
2.0
0.40
0.31
0.55
8.1
9
1 Full plate
Paneer Pulao
520
13.3
20.4
70.9
4.3
272.0
4.9
2.0
0.40
0.21
0.13
3.3
6
1 Full plate
Mutton Pulao
622
22.6
28.5
68.7
4.3
216.0
5.1
13.0
12.00
0.37
0.29
8.8
6
1 Full plate
Chicken Pulao
661
27.9
30.5
68.7
4.3
110.0
4.6
88.0
90.00
0.33
0.34
11.4
6
1 Full plate
Idli
157
6.7
0.5
31.5
2.5
33.00
1.6
8.00
2.00
0.14
0.08
1.4
0
3 or 4
Plain Dosa
261
7.1
4.6
47.8
3.2
28.00
1.6
166.0
41.00
0.17
0.08
2.2
0
2
Masala Dosa
208
3.0
4.2
39.5
4.5
39.00
1.1
36.0
9.00
0.19
0.02
2.0
31
1
Mixed Vegetable
184
4.8
4.4
31.2
4.2
79.00
1.8
624.0
156.00 0.20
0.10
1.8
43
1
Dosa
Paneer Filling
130
3.8
8.8
8.9
1.3
144.0
0.6
176.0
44.00
0.10
0.00
0.4
19
1
Uttapam
316
7.8
8.7
51.6
3.9
55.00
2.1
465.0
116.00 0.20
0.10
2.5
23
2
Beans and
352
12.1
16.8
38.0
3.7
243.0
2.2
673.0
242.00 0.20
0.20
1.5
40
1 Plate
Macaroni
Spaghetti
346
14.6
14.9
38..3
33.0
174.0
3.2
867.0
236.00 0.28
0.21
4.8
30
1 Shallow dish
Bolognese
Chicken
542
31.4
24.2
49.6
3.9
104.0
5.6
9.8
333.00 0.39
0.36
8.1
59
1 Shallow dish
Chowmein
PULSES
Dal Moong
104
7.3
0.4
17.9
2.6
23.0
1.2
15.0
4.00
0.14
0.06
0.7
0
1 Curry Bowl
Cumin Seed
47
0.0
5.0
0.5
0.0
0.0
0.0
100.0
25.00
0.00
0.00
0.0
0
Baghar
Onion Tomato
59
0.4
5.1
2.8
0.5
17.0
0.2
153.0
38.00
0.03
0.01
0.1
6
Baghar
Mustard Seed
45
0.0
5.0
0.0
0.0
0.0
0.0
100.0
25.00
0.00
0.00
0.0
0
Baghar
Urad Sp.
94
7.9
5.5
3.3
3.1
78.0
1.5
82.0
21.00
0.19
0.08
0.9
11
1 Curry Bowl
Dehusked Dry
Arhar Daal
159
7.7
5.9
18.7
4.4
58.0
1.4
2830.0 707.00 0.50
0.19
1.1
14
1 Curry Bowl
with Spinach
Channa Daal
117
6.3
1.7
19.1
3.4
27.0
1.8
39.0
10.00
0.16
0.06
0.8
0
1 Curry Bowl
with Ghia
Sambar
119
5.6
2.5
18.4
3.2
45.0
1.7
88.0
22.00
0.13
0.08
0.9
19
1 Curry Bowl
Green Gram
100
7.2
0.4
17.0
1.2
37.0
1.3
28.0
7.00
0.14
0.08
0.6
0
1 Bowl
Whole
Dry Khatta
232
6.0
11.7
25.6
4.8
83.0
1.9
369.0
91.00
0.16
0.07
1.3
14
1 Bowl
Channa
Rajma Curry
268
10.5
11.0
31.8
3.7
162.0
2.6
193.0
49.00
0.29
0.12
1.2
20
1 Bowl
Lobia Curry
259
10.9
10.9
29.3
2.8
89.0
4.1
182.0
46.00
0.31
0.12
0.9
19
1 Bowl
Besan Gatte
497
21.3
30.6
34.0
5.5
255.0
2.9
367.0
96.00
0.34
0.22
1.4
14
1 Bowl
Curry
Besan Kadhi
408
9.9
30.2
24.1
3.7
140.0
2.2
73.0
23.00
0.21
0.19
1.0
1
1 Bowl
with Pakoris
Calories Proteins Fats
Carbo- Fiber
Calcium Iron
Caro-
Retinol Vit B1
Vit B2
Niacin
Vit C
Serving
(Kcal)
(g)
(g)
hydrates (g)
(mg)
(mg)
tene
(mcg)
(mg)
(mg)
(mg)
(mg)
Portion
(g)
(mcg)
Contd.
Contd.

582
Principles and Practice of Burn Care
MEATS
Keema Matar
411
26.9
23.7
22.6
2.8
215.0
4.9
298.0
84.00
0.53
0.19
8.0
29
1 Bowl
Roganjosh
404
25.0
30.6
7.2
0.8
276.0
4.0
114.0
45.00
0.31
0.27
8.0
12
1 Bowl
Mutton Korma
439
24.0
34.7
7.7
0.8
259.0
3.7
149.0
54
0.30
0.22
8.50
6.0
1 Bowl
Palak Meat
374
19.1
28.4
10.6
5.2
290.0
3.8
5600.0 1410
0.24
0.46
620
34.0
1 Bowl
Shahi Keema
508
23.8
41.3
10.2
1.5
238.0
4.3
217.0
65
0.34
0.21
8.70
23.0
1 Bowl
Kofta Curry
Boti Kabab
365
23.6
27.8
5.0
0.5
232.0
3.6
8.0
19
0.24
0.22
8.30
9.0
1 Bowl
Shammi Kabab
435
25.0
25.8
25.8
3.6
180.0
3.4
890.0
58.00
0.29
0.21
7.4
3.7
1 Bowl
Shepherd’s Pie
486
23.8
34.5
20.0
2.2
206.0
3.5
339.0
98.00
0.31
0.18
9.2
15
1 Bowl
Roast Chicken
297
25.3
21.8
0.0
0.0
18.0
2.0
334..0
166.0
0.13
0.20
10.0
0
1 Bowl
Chilli Chicken
464
27.3
35.5
8.8
1.9
46.0
3.1
222.0
135.0
0.35
0.31
10.9
50
1 Bowl
Chicken Sweet
420
27.0
33.3
3.1
0.8
39.0
2.7
270.0
181.0
0.28
0.35
10.6
30
1 Bowl
and Sour
Chicken Korma
493
28.1
36.4
13.2
2.1
188.0
3.2
94.0
127.0
0.23
0.32
10.2
11
1 Bowl
Bengal Fish
296
18.4
17.5
16.3
1.6
731.0
1.7
22.4
7.00
0.14
0.11
1.1
35
1 Bowl
Curry
Tandoori Fish
174
25.7
6.8
2.4
0.0
7.0
3.1
10.0
11.00
0.01
0.02
0.0
0
1 Bowl
Fried Fish with
443
26.3
26.2
25.4
2.3
307.0
3.3
165.0
94.00
0.09
0.11
0.9
9
1 Bowl
Chips
Fish in Coconut
371
27.0
17.1
27.2
3.2
150.0
3.2
4.0
1.00
0.06
0.03
0.5
7
1 Bowl
Milk
Prawn Curry
342
30.1
19.9
10.5
2.7
509.0
9.3
3.0
0.80
0.05
0.18
7.5
4
1 Bowl
Crispy Baked
390
32.3
15.1
31.2
4.1
461.0
4.1
496.0
153.00 0.13
0.13
1.3
16
1 Bowl
Fish
VEGETABLES
AND PANEER
Nutri Nugget
252
12.8
18.3
9.1
8.0
22.0
1.0
180.0
79.00
0.16
0.16
1.0
30
1 Bowl
Sweet and Sour
Nutri Nugget
347
14.2
23.4
20.0
2.1
217.0
1.4
28.0
12.00
0.11
0.13
0.6
11
1 Bowl
Korma
Mashrooom
239
10.3
10.8
25.2
2.8
68.5
3.3
298.0
75.00
0.41
0.30
4.1
31
1 Bowl
Matar
Nutri Nugget
283
18.4
10.5
28.6
2.8
68.5
2.4
298.0
75.00
0.35
0.05
1.0
29
1 Bowl
Matar
Palak Mushroom
161
5.2
10.6
11.3
7.7
149.0
2.9
708.0
2177.000.17
0.59
3.0
60
1 Bowl
Vegetable
394
17.1
33.1
6.8
6.7
188.0
2.0
146.0
103.0
0.30
0.06
2.6
43
1 Bowl
Nargisi Kofta
Curry
Paneer Makhani
659
9.5
61.3
17.4
3.0
305.0
2.9
2046.0 580.0
0.36
0.19
1.3
64
1 Bowl
Pea Potato
267
8.9
10.3
34.6
4.1
62.8
2.2
165.0
41.00
0.37
0.03
1.7
30
1 Bowl
Curry
Pea Paneer
351
17.3
20.8
23.6
2.8
162.0
2.0
153.0
94.00
0.36
0.04
1.1
23
1 Bowl
Curry
Pea Curry
311
15.3
10.3
39.2
4.5
78.0
3.5
236.0
60.00
0.60
0.04
2.0
30
1 Bowl
Pea/Cholia Vadi
309
11.7
15.3
31.0
3.7
68.0
2.8
195.0
49.00
0.50
0.03
1.5
26
1 Bowl
Curry
Potato Curry
221
2.5
10.2
29.9
3.6
47.7
1.0
94.0
23.60
0.17
0.03
1.5
29
1 Bowl
Egg Curry
314
15.5
17.6
23.3
2.8
85.0
2.8
483.0
237.00 0.38
0.25
1.2
21
1 Bowl
Dahi Aloo
260
4.2
12.2
33.4
3.9
119.0
1.0
169.0
58.00
0.22
0.12
1.8
35
1 Bowl
Dum Aloo
291
2.1
21.1
23.2
2.5
41.5
0.5
29.0
8.00
0.11
0.03
1.2
17
1 Bowl
Ghia Kofta
273
3.6
20.9
17.5
2.9
70.0
1.9
122.0
31.00
0.17
0.05
0.9
15
1 Bowl
Curry
Potato Kofta
290
2.9
15.3
35.1
4.1
51.0
1.3
101.0
25.00
0.19
0.03
1.80
33
1 Bowl
Curry
Calories Proteins Fats
Carbo- Fiber
Calcium Iron
Caro-
Retinol Vit B1
Vit B2
Niacin
Vit C
Serving
(Kcal)
(g)
(g)
hydrates (g)
(mg)
(mg)
tene
(mcg)
(mg)
(mg)
(mg)
(mg)
Portion
(g)
(mcg)
Contd.
Contd.

Appendices
583
Cabbage Kofta
297
5.9
21.0
21.0
4.0
85.0
2.1
210.0
52.00
0.20
0.14
1.1
136
1 Bowl
Curry
Paneer Kofta
383
11.2
30.7
15.5
1.5
149.0
0.9
74.0
74.00
0.13
0.04
0.6
15
1 Bowl
Curry
Aloo Methi
221
5.8
11.0
24.7
4.1
404.0
2.5
2361.0 590.00 0.12
0.32
1.8
66
1 Bowl
Gajar Methi
180
5.2
11.0
15.0
3.5
460.0
2.8
3854.0 963.00 0.08
0.33
1.3
55
1 Bowl
Sarson Ka Saag
157
8.5
6.7
15.7
3.2
200.0
25.0
6734.0 1682.000.22
0.14
0.5
66
1 Bowl
Palak Paneer
240
11.2
17.5
9.4
7.7
228.0
2.1
8545.0 2180.000.16
0.43
1.1
59
1 Bowl
Palak Aloo
230
5.1
11.3
27.0
9.7
153.0
2.5
8564.0 2141.000.20
0.40
2.0
72
1 Bowl
Mooli Bhujia
144
4.6
10.6
7.6
2.3
294.0
0.8
5300.0 2.00
0.23
0.49
1.2
91
1 Bowl
Bathua Bhujia
152
6.0
10.7
7.8
0.3
236.0
6.8
2614.0 1.00
0.04
0.22
1.0
55
1 Bowl
Peas and
122
5.5
5.2
13.2
2.2
50.0
1.7
164.0
41.00
0.19
0.10
0.8
129
1 Bowl
Cabbage Subzi
Dry Arbi (Fried)
254
3.6
15.2
25.6
1.6
62.0
0.9
79.0
14.00
0.14
0.04
0.6
8
1 Bowl
Masala Arbi
187
3.0
10.1
21.1
1.0
40.0
0.4
24.0
0.00
0.09
0.03
0.4
0
1 Bowl
Bingan Bhartha
192
2.8
15.5
10.4
4.5
55.0
0.9
216.0
54.00
0.12
0.19
1.6
29
1 Small Bowl
Stuffed Tomatoes 233
6.0
15.6
17.1
2.8
138.0
1.5
829.0
228.00 0.27
0.08
1.1
41
2 Tomatoes
Bhindi Subzi
189
2.6
15.0
11.0
6.3
93.0
0.7
62.0
16.00
0.11
0.12
0.8
19
1 Bowl
Stuffed Bhindi
132
2.3
10.2
7.7
5.9
79.0
0.5
62.0
16.00
0.08
0.12
0.7
16
1 Bowl
Stuffed Karela
225
1.9
20.2
8.9
2.6
39.0
1.0
101.0
25.00
0.10
0.08
0.6
76
1 Bowl
(Wet)
Stuffed Karela
156
1.3
15.2
3.4
1.8
16.0
0.5
100.0
25.00
0.06
0.07
0.4
70
3 Pcs
(Dry)
Kathal (Dry)
300
2.2
20.3
27.0
7.1
89.5
1.3
201.0
51.00
0.15
0.02
1.1
12
1 Bowl
Cauliflower, Peas
196
5.1
10.3
20.7
2.9
49.0
1.6
143.0
36.00
0.21
0.07
1.4
42
1 Bowl
and Potato
Subzi
Stuffed Ghia
456
21.3
31.8
21.1
2.5
323.0
2.9
632.0
304.00 0.22
0.34
4.1
3
1/2 Marrow
Rost Potatoes
191
2.4
5.0
34.0
3.8
15.0
0.8
228.0
57.00
0.15
0.01
1.8
26
1-2 Potatoes
Stuffed Baked
334
7.1
18.8
34.0
3.8
33.0
1.3
698.0
248.00 0.19
0.16
1.8
26
1-2 Potatoes
Potato
Creamed
429
21.4
29.8
18.8
9.3
458.0
3.5
11812.03195.000.25
1.00
1.4
58
1 Small Bowl
Spinach
Creamed
363
13.4
25.8
19.2
7.1
366.0
2.9
8692.0 2284.000.23
0.90
3.5
45
1 Bowl
Spinach and
Mushrooms
SALADS
Russian Salad
959
19.7
85.6
27.5
3.3
100.0
3.8
879.0
333.00 0.38
0.33
5.4
39
1 Small Bowl
Beetroot and
366
8.9
30.8
13.4
3.6
62.0
2.1
300.0
180.00 0.12
0.29
0.6
15
1 Small Bowl
Egg Salad
Tossed Green
153
1.5
12.2
9.2
2.0
50.0
0.9
225.0
57.00
0.18
0.04
0.5
43
1 Small Bowl
Salad
Cucumber and
29
1.3
1.3
2.9
1.0
53.0
0.5
10.0
4.00
0.04
0.05
0.2
6
1 Small Bowl
Yogurt Salad
French Dressing
722
0.0
80.0
0.4
0.0
1.0
0.0
0.0
0.00
0.00
0.00
0.01
1
3/4 Cup
Mayonnaise
1220
7.1
131.8
1.3
0.0
56.0
1.4
380.0
229.00 0.08
0.26
0.0
4
1 Cup
Mayonnaise
886
7.7
90.1
11.0
0.0
288.0
0.5
139.0
36.00
1.20
0.46
0.3
6
1 Cup
without Eggs
RAITAS
Tomato Onion
79
3.7
4.1
6.7
0.6
173.0
0.5
120.0
36.00
0.10
0.18
0.3
11
1 Bowl
Raita
Cucumber Raita
68
3.3
4.1
4.5
0.8
155.0
0.6
32.0
14.00
0.07
0.16
0.2
5
1 Bowl
Carrot Raita
85
3.6
4.1
8.3
0.9
189.0
0.7
977.0
250.00 0.07
0.17
0.4
3
1 Bowl
Calories Proteins Fats
Carbo- Fiber
Calcium Iron
Caro-
Retinol Vit B1
Vit B2
Niacin
Vit C
Serving
(Kcal)
(g)
(g)
hydrates (g)
(mg)
(mg)
tene
(mcg)
(mg)
(mg)
(mg)
(mg)
Portion
(g)
(mcg)
Contd.
Contd.

584
Principles and Practice of Burn Care
Ghia Raita
67
3.2
4.1
4.3
0.3
159.0
0.4
32.0
14.00
0.06
0.17
0.2
1
1 Bowl
Potato Raita
110
3.9
4.1
14.3
1.3
154.0
0.5
44.0
17.00
0.10
0.17
0.7
10
1 Bowl
Spinach Raita
143
7.7
8.7
8.5
4.9
231.0
1.6
5616.0 1410.000.17
0.43
2.6
29
1 Bowl
Bathua Raita
147
9.3
8.4
8.5
0.4
308.0
4.7
1776.0 15.00
0.15
0.31
2.7
36
1 Bowl
Sprouted Green
105
5.8
4.1
11.2
1.2
166.0
0.7
37.0
15.00
0.11
0.18
0.4
3
1 Bowl
Gram Raita
Boondi Raita
224
7.3
15.0
15.0
2.1
160.0
1.3
58.0
21.00
0.15
0.20
0.6
1
1 Bowl
Pineapple Raita
84
3.3
4.1
8.4
0.0
159.0
1.4
41.0
16.00
0.15
0.22
0.2
21
1 Bowl
Banana Raita
118
3.7
4.1
16.6
0.4
158.0
0.4
71.0
24.00
0.08
0.20
0.4
5
1 Bowl
Mango Raita
97
3.4
4.2
11.5
0.5
156.0
0.9
1404.0 357.00 0.09
0.20
0.6
9
1 Bowl
Grape Raita
91
3.4
4.2
10..0
1.4
159.0
0.5
33.0
14.00
0.06
0.17
0.2
2
1 Bowl
DESSERTS
Rice Kheer
257
7.2
8.3
38.3
0.4
241.0
0.7
12.0
104.00 0.12
0.40
0.6
4
1 Bowl
Sevian Kheer
271
7.9
9.2
39.2
1.2
273.0
0.6
12.0
111.00 0.12
0.40
0.4
4
1 Bowl
Carrot Kheer
218
6.9
8.3
29.0
0.9
280.0
0.9
957.0
340.00 0.12
0.38
0.5
6
1 Bowl
Apple Kheer
244
6.5
8.5
35.4
0.6
245.0
0.8
12.0
104.00 0.10
0.38
0.2
5
1 Bowl
Phirni
258
7.1
8.3
38.8
0.4
241.0
0.5
12.0
104.00 0.11
0.39
0.4
4
1 Bowl
Carrot Halva
472
8.3
24.5
54.5
2.7
443.0
1.6
3137.0 844.00 0.14
0.30
1.0
7
1 Small Bowl
Suji Halwa
380
3.6
23.2
39.1
0.8
16.0
0.7
400.0
100.00 0.04
0.04
0.6
0
1 Small Bowl
Moong Dal
545
13.8
28.2
59.0
2.7
310.0
1.2
415.0
149.00 0.22
0.27
0.9
2
1 Small Bowl
Halwa
Vanilla Ice
288
2.3
22.9
18.2
0.0
90.0
0.2
415.0
139.00 0.03
0.14
0.1
0
1 Ice Cream
Cup
Cream
Strawberry Ice
288
2.3
22.9
18.2
0.0
90.0
0.2
415.0
139.00 0.03
0.14
0.1
0
1 Ice Cream
Cup
Cream
Chocolate Ice
288
2.3
22.9
18.2
0.0
90.0
0.2
415.0
139.00 0.03
0.14
0.1
0
1 Ice Cream
Cup
Cream
Chocochip Ice
288
2.3
22.0
18.2
0.0
90.0
0.2
415.0
139.00 0.03
0.14
0.1
0
1 Ice Cream
Cup
Cream
Choconut Ice
460
5.5
30.5
40.8
0.0
106.0
1.0
411.0
414.00 0.10
0.18
0.4
2
1 Sundae Glass
Cream
Fruit Ice Cream
323
2.6
23.0
26.5
0.3
95.0
0.4
832.0
246.00 0.05
0.16
0.3
5
1 Sundae Glass
Cold Lemon
534
6.9
41.9
32.3
0.4
41.0
0.8
1000.0 355.00 0.05
0.20
0.1
8.8
1 Sooffle Dish
Souffle
Cold Orange
594
7.8
42.0
46.2
1.5
64.0
1.2
2656.0 769.00 0.05
0.20
0.1
45
1 Souffle Dish
Souffle
Cold Pineappple
525
6.7
42.0
30.00
0.0
25.0
0.7
1000.0 355.00 0.00
0.20
0.1
0
1 Souffle Dish
Souffle
Cold Vanila
536
7.3
42.7
30.6
0.0
57.0
0.7
1000.0 362.00 0.06
0.20
0.1
0.2
1 Souffle Dish
Souffle
Cold Chocolate
536
7.3
42.7
30.6
0.0
57.0
0.7
1000.0 362.00 0.06
0.20
0.1
0.2
1 Souffle Dish
Souffle
Bread and
222
7.4
11.3
22.7
1.0
124.0
0.7
316.0
177.00 0.08
0.27
0.2
2
1 Small Plate
Butter Pudding
SNACKS
Gulabjamuns
329
6.7
12.9
46.6
0.2
279.0
0.2
145.0
36.00
0.23
0.17
0.3
2
2 Pcs
Chenna Murkhi
275
9.3
10.6
35.6
0.0
110.0
0.0
186.0
47.00
0.06
0.02
0.0
2
10 Pcs
Plain Barfi
276
10.0
13.0
29.8
0.0
478.0
0.0
249.0
63.00
0.12
0.21
0.2
3
2 Pcs
Coconut Barfi
472
11.7
28.6
41.9
4.3
578.0
2.0
249.0
63.00
0.14
0.21
1.0
5
2 Pcs
Calories Proteins Fats
Carbo- Fiber
Calcium Iron
Caro-
Retinol Vit B1
Vit B2
Niacin
Vit C
Serving
(Kcal)
(g)
(g)
hydrates (g)
(mg)
(mg)
tene
(mcg)
(mg)
(mg)
(mg)
(mg)
Portion
(g)
(mcg)
Contd.
Contd.

Appendices
585
Besan Burfi
266
5.3
13.9
30.0
2.7
14.0
1.3
282.0
71.00
0.12
0.05
0.6
1
2 Pcs
Khoya Laddoo
375
10.7
22.2
33.0
1.8
441.0
1.4
206.0
52.00
0.14
0.21
0.8
3
2 Pcs
Besan Laddoo
286
5.8
16.4
28.7
2.8
15.0
1.4
332.0
83.00
0.13
0.05
0.7
1
2 Pcs
Suji Laddoo
290
3.4
16.7
31.4
0.8
16.0
0.8
306.00 77.00
0.09
0.03
0.5
0
2 Pcs
with Nuts
Suji Laddoo
355
5.6
20.1
38.0
1.9
125.0
0.6
312.00 78.00
0.07
0.07
0.5
1
2 Pcs
with Khoya
Til Laddo
158
3.2
7.2
20.0
0.0
256.0
2.0
10.0
3.00
0.18
0.07
0.8
0
6 Pcs
Gujia
272
4.8
13.2
33.6
1.3
114.0
0.9
121.0
31.00
0.05
0.06
0.7
1
6 Pcs
Peanut Brittle
229
5.2
8.1
33.7
0.9
44.0
1.3
7.00
2.00
0.20
0.06
4.1
0
5 Pcs
(Chikki)
Til and Channa
217
5.2
3.3
41.7
2.1
110.0
2.3
29.00
7.00
0.16
0.09
0.8
0
5 Pcs
Chikki
Murmura Chikki
139
0.7
0.0
34.0
0.4
28.0
1.3
0.0
0.00
0.03
0.03
0.4
0
5 Pcs
Vegetable
333
7.8
21.9
26.2
5.2
49.0
2.3
1166.0 291.00 0.19
0.13
1.3
23
5 Pcs
Pakoras
Masala Onion
343
7.5
21.8
29.1
4.7
64.0
2.2
39.0
10.00
0.20
0.06
1.1
11
5 Pcs
Pakoras
Paneer Pakoras
425
15.5
32.1
18.6
3.2
121.0
1.6
222.0
56.00
0.18
0.06
0.7
2
5 Pcs
Bread Pakoras
489
11.8
22.2
60.5
8.6
28.0
2.5
51.00
13.00
0.24
0.06
1.7
9
5 Pcs
Egg Pakoras
380
13.0
28.4
18.0
3.2
42.0
2.3
339.00 190.00 0.19
0.25
0.8
0
2 Pcs
Chicken Pakoras
451
22.6
31.8
18.7
3.2
29.0
3.0
1.1
78.00
0.23
0.18
7.2
1
2 Pcs
Fish Cutlets
373
19.7
22.8
22.2
3.2
538.0
2.6
41.00
10.00
0.19
0.11
1.3
18
2 Pcs
Bonads
457
10.7
25.8
45.5
6.4
45.0
2.5
66.00
7.00
0.35
0.08
4.0
20
2 Pcs
Vegetable Cutlets
216
4.6
10.3
26.2
3.0
36.0
1.2
600.00 150.00 0.13
0.02
1.0
9
2 Pcs
Paneer Cutlets
330
14.5
24.7
12.3
1.2
148.0
0.3
257.00 65.00
0.07
0.02
0.2
2
2 Pcs
Sago Cutlets
293
1.7
10.2
48.7
2.5
13.0
0.9
24.00
6.00
0.10
0.01
1.2
17
2 Pcs
Chirwa Cutlets
325
6.8
10.7
50.4
2.6
41.0
9.1
593.00 148.00 0.19
0.03
2.2
4
2 Pcs
Fish Cutlets
470
19.1
31.6
27.2
2.3
658.0
1.6
13.00
3.00
0.12
0.08
1.5
31
2 Pcs
Keema Cutlets
307
1.8
23.6
21.9
1.1
155.0
3.0
1.00
9.00
0.21
0.14
7.2
0
2 Pcs
Vegetable
246
4.4
12.0
30.2
1.0
19.0
1.1
131.00 33.00
0.13
0.02
1.3
12
2 Pcs
Samosas
Paneer Pea
255
6.2
16.5
20.5
0.8
110.0
0.9
119.00 30.00
0.08
0.02
0.9
3
2 Pcs
Samosas
Keema Samosas
262
10.0
17.0
17.3
2.8
80.0
1.7
164.00 45.00
0.13
0.08
3.3
6
2 Pcs
Mathri
223
2.8
15.3
18.5
2.1
6.0
0.7
6.00
21.00
0.03
0.02
0.6
0
2 Pcs
Masala Vada
179
6.6
8.6
18.7
2.8
24.0
1.3
39.00
10.00
0.15
0.06
0.8
1
2 Pcs
Plain Urad Daal
171
7.2
7.9
17.8
2.1
46.0
1.1
11.00
3.00
0.13
0.06
0.06
0
2 Pcs
Vada
Masala Urad
198
7.5
10.0
19.6
2.8
51.0
1.3
11.00
3.00
0.14
0.07
0.07
1
2 Pcs
Daal Vada
Mint and
17
0.6
0.1
3.4
0.3
28.0
1.7
43.00
108.00 0.01
0.02
0.1
8
1 T
Coriander
Chutney
Tomato Ginger
6
0.3
0.1
1.0
0.3
12.0
0.2
88.00
22.00
0.03
0.02
0.1
7
2 T
Chutney
SANDWICHES
Tomato and
268
7.2
11.8
33.3
4.6
88.0
0.9
460.0
145.00 0.09
0.06
0.6
11
2 Pcs
Cheese
Tomato and
231
5.2
8.6
33.1
4.9
28.0
1.0
460.0
115.00 0.10
0.02
0.6
12
2 Pcs
Cucumber
Tomato Grilled
313
9.6
15.0
34.8
5.0
160.0
1.2
530.0
192.00 0.12
0.12
0.6
16
4 Pcs
French Toast
443
14.6
27.6
34.0
4.6
144.0
1.7
1088.0 407.00 0.15
0.20
0.6
11
2 Pcs
Cheese Open
340
11.7
18.6
31.5
7.4
196.0
1.1
328.0
168.00 0.14
0.11
1.5
0
2 Pcs
Calories Proteins Fats
Carbo- Fiber
Calcium Iron
Caro-
Retinol Vit B1
Vit B2
Niacin
Vit C
Serving
(Kcal)
(g)
(g)
hydrates (g)
(mg)
(mg)
tene
(mcg)
(mg)
(mg)
(mg)
(mg)
Portion
(g)
(mcg)
Contd.
Contd.