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:



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.

  1. Etiology – the cause of the burn (e.g. flame, hot water, acid)
  2. Intensity – temperature and viscosity of the drink/food or concentration of the chemical agent
  3. Quantity – volume (e.g. pot versus cup of tea or splash versus immersion)
  4. Duration – amount of time the patient was exposed (also consider the condition of the skin)
  5. 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 burnChemical burn
EtiologyFlame/contact/scald (and nature of scalding)Agent/chemical substance
IntensityTemperature and viscosity of the drink/foodConcentration of the chemical agent
QuantityPot of tea versus cup of teaSplash versus immersion
DurationDuration of exposure/contactDuration of contact; also consider the condition of the skin
First aidAction taken at the sceneAction taken at the scene
Different questions must be asked in order to get an impression of the extent of a burn wound

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

Burn wound assessment

To carry out the physical examination, start with the head and face and work systematically towards the limbs.

LocationPhysical examination
FacePalpate the midface, including the bony margins of the orbit, maxilla, nose and jaw. The jaw should be inspected for pain or trismus (lockjaw).
ScalpOn the scalp look for lacerations and bruises; mastoid and periorbital bruising in particular may indicate a skull base fracture.
EyesCheck 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.
EarsLook for any signs of a cerebrospinal fluid leak, bleeding or blood behind the tympanic membrane. Also check the patient’s hearing.
NoseLook for any deformities, bleeding, nasal septal hematoma and any signs of cerebrospinal fluid leak.
MouthLook for lacerations, edema, loose or missing teeth, and soot on the tongue or pharynx, as this may indicate inhalation injury.
NeckAlways 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.
ChestInspect 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.
BackLog 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.
AbdomenInspect 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.
PelvisCarefully 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.
PerineumInspect 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.
LimbsLook 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:

  1. Primary and secondary survey
  2. Laboratory investigations
  3. Tests and tubes
  4. Electrocardiogram
  5. Tetanus administration

Secondary survey: assessing a patient with burns


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