BACKGROUND The Formosa Fun Coast Dust Explosion is one of the major national disasters in Taiwan. The Taipei City Hospital (TCH), a regional hospital without a burn unit, received 33 patients out of 499 casualties in the initial response period. This retrospective study aimed to review the primary response of TCH and the outcome and mortality of the patients who were initially managed at TCH. METHODS Basic profi les, total body surface area (TBSA) with burn injury, facial burn injury, vital signs, laboratory data, intubation rate and clinical outcomes, such as urine output and mortality, were analyzed. Moreover, the emergency department (ED) response faculties, who were involved in the initial response, were interviewed about the critical decision-making processes during the patient surge in the ED. RESULTS The average initial estimated TBSA with burn injury in ED was 34.2%, and the average final TBSA assessed in the intensive care unit was 41.0%. The patients with facial burn injury were 38.7%, and the intubation rate was 22.6%. When comparing the result of TCH to the patient group transferred directly to Chang Gung Memorial Hospital (CGMH), and the group received by CGMH from other hospital, the mortality rate was 0.0, 5.7, 9.1%; and the delayed intubation rate was 3.0, 14.3, 27.3%, respectively. The key elements for effi cient initial response were the multidisciplinary response team cooperated as a production line, using the clipboards for orders recordings, and the plastic surgeons ED-operating room (OR) direct transferring. CONCLUSIONS Regarding airway complications, and mortality, patients who were initially managed in TCH had comparable results with patients directly sent to the burn centers. This study supports the notion that immediate resuscitation in multiple level of hospitals, even without burn units but with adequate recruited response personnel, provided the best chance for the survival of casualties during such national disasters.