Secondary survey: assessing a patient with burns
When you have excluded or addressed life-threatening conditions in the primary survey, continue with a secondary survey. This involves taking the patient’s history and assessing the wound.
Take a history
Check the patient’s identity, then take a history using the AMPLE approach:
Allergies
Medications
Past medical illnesses
Last meal
Events / environment related to injury
Take a burn-specific history
Next, take a burn-specific history according to the following five points.
- Etiology – the cause of the burn (e.g. flame, hot water, acid)
- Intensity – temperature and viscosity of the drink/food or concentration of the chemical agent
- Quantity – volume (e.g. pot versus cup of tea or splash versus immersion)
- Duration – amount of time the patient was exposed (also consider the condition of the skin)
- First aid – actions taken at the accident site
If there is any information missing, ask family members or people who witnessed the event.
5-point history - differences between thermal and chemical burns
| Thermal burn | Chemical burn | |
|---|---|---|
| Etiology | Flame/contact/scald (and nature of scalding) | Agent/chemical substance |
| Intensity | Temperature and viscosity of the drink/food | Concentration of the chemical agent |
| Quantity | Pot of tea versus cup of tea | Splash versus immersion |
| Duration | Duration of exposure/contact | Duration of contact; also consider the condition of the skin |
| First aid | Action taken at the scene | Action taken at the scene |
Non-accidental burns: how to spot them and what to do
While most burns are unintentional, non-accidental injury is not uncommon. Children and the elderly are particularly vulnerable to non-accidental burns.
During the survey, you should look out for signs of neglect or mistreatment, especially in children.
If you suspect a child’s burn is non-accidental, always refer them to a burn center.
Raise suspicions when:
- History of the event does not match the pattern of the injury
- History is not clear, contradictory or changing
- Presentation is delayed
- Previous injury has occurred
- Parents were not present at the time of the accident or during admission to hospital
Spot the patterns of non-accidental injury:
- Sock or glove pattern indicates immersion
- Cigarette marks
- Donut sign
Traditional healing
In low and middle-income countries, patients may have been treated by traditional healers before being admitted to your healthcare facility. This may have been decided due to traditional beliefs and/or access and affordability of healthcare.
Traditional treatment may include application of herbal products, eggs and ashes. It can result in late presentations with severe complications, including sepsis.
Full body physical examination
First remove all clothes to reveal any hidden wounds. This step is essential for the treatment of the burn wounds.
You can find detailed information on how to perform the burn wound assessment on the page
To carry out the physical examination, start with the head and face and work systematically towards the limbs.
| Location | Physical examination |
|---|---|
| Face | Palpate the midface, including the bony margins of the orbit, maxilla, nose and jaw. The jaw should be inspected for pain or trismus (lockjaw). |
| Scalp | On the scalp look for lacerations and bruises; mastoid and periorbital bruising in particular may indicate a skull base fracture. |
| Eyes | Check the eyes for any foreign bodies, subconjunctival hemorrhage, hyphema, irregular iris, penetrating injury or contact lenses. Also check pupillary reflexes, visual acuity and eye movement. |
| Ears | Look for any signs of a cerebrospinal fluid leak, bleeding or blood behind the tympanic membrane. Also check the patient’s hearing. |
| Nose | Look for any deformities, bleeding, nasal septal hematoma and any signs of cerebrospinal fluid leak. |
| Mouth | Look for lacerations, edema, loose or missing teeth, and soot on the tongue or pharynx, as this may indicate inhalation injury. |
| Neck | Always suspect cervical spine injury if there is a traumatic mechanism involved, and therefore apply a cervical collar. Inspect, palpate and investigate further by taking X-rays or a CT scan, according to hospital protocols. |
| Chest | Inspect the whole chest, including the back by log rolling the patient. Palpate the chest for rib tenderness and subcutaneous emphysema, and auscultate the lung fields and heart sounds. If ventilation is compromised due to circumferential burns, perform an escharotomy. |
| Back | Log roll the patient and look for any deformity, bruising or lacerations. Palpate the spine for tenderness or step-offs between vertebrae. A digital rectal examination should only be performed if spinal injury is suspected. |
| Abdomen | Inspect for bruising, lacerations, penetrating injury and presence of a seatbelt sign. Palpate for distension and areas of tenderness and re-evaluate the patient frequently for any increase in these. If the assessment is unreliable or equivocal, investigate further with a CT scan or FAST ultrasound. |
| Pelvis | Carefully palpate for any tenderness but take an X-ray if there is any suspicion of injury. Do not perform a pelvic spring test, as additional manipulation may exacerbate any hemorrhage. |
| Perineum | Inspect for any blood or bruising. Assess the rectum for any blood, lacerations or high riding prostate (if present), including an evaluation of the sphincter tone. If present, the vagina should be inspected for any foreign bodies or lacerations. If urethral bleeding is observed, first perform a urethrogram before an IUD is placed. |
| Limbs | Look for any deformity, tenderness or crepitus. Assess for signs of decreased limb perfusion, including pain, paresthesia, pulselessness and paralysis. If vascular insufficiency is present due to (semi-) circumferential burns, perform an escharotomy. |
Document your findings
To make sure the patient gets the best possible treatment, it is vital you document all your findings from the primary and secondary survey accurately. Re-evaluate all information, including:
- Primary and secondary survey
- Laboratory investigations
- Tests and tubes
- Electrocardiogram
- Tetanus administration