Primary survey: ABCDEF
You should conduct the primary survey for every adult burn patient. The order of assessment is designed to ensure that the most life-threatening issues are treated first. It is therefore vital you follow the process in order, even if the burn injury distracts you from other injuries.
If the patient is a child, you will need to make adjustments to the primary survey – you can find the correct process on the page about children:
Secure your own safety first
Always secure your own safety before helping a burn patient. Once you are safe, you can begin to stop the burn and help the patient.
- Maintain the airway while protecting the cervical spine.
- Check that the airway is patent and free of any obstruction, indicated if the patient is able to speak.
- If the patient cannot speak, secure the airway.
- The onset of symptoms of inhalation injury may be delayed, so it is important to re-evaluate the airway.
- Check for cervical spine injury. Injuries proximal to the clavicle are often associated with cervical spine injury, such as those caused by loss of consciousness and facial wounds. If you suspect injury to the cervical spine, or if the mechanism of trauma is unknown, stabilize the cervical spine.
Breathing & ventilation
1 Apply the principles of look, listen, feel:
Look by fully exposing the chest to assess the symmetry of the chest wall motion and the position of the trachea. Measure respiratory rate: a respiratory rate of <10 breaths per minute or >30 breaths per minute are cause for concern.
Listen for stridor and assess bilateral air movement, crepitus and rhonchi by auscultating the lungs.
Feel by palpating the chest for pain and subcutaneous emphysema.
2 Use a pulse oximeter to monitor oxygen levels. All major trauma patients should receive at least 15L of oxygen per minute. If 15L is not available, supply the maximum amount available.
3 If breathing is insufficient, assist ventilation by using a bag valve mask or intubate the patient.
4 Identify any (semi-) circumferential burns on the trunk or neck that may impair respiration. Perform a rapid bedside escharotomy when there are circumferential burns of the trunk or neck.
5 Assess the patient for signs of carbon monoxide (CO) poisoning, which can lead to hypoxemia. CO poisoning should be suspected in a patient with cherry pink mucous membranes and an altered level of consciousness. Oxygen saturation level cannot be used as an indicator in CO poisoning, as it will be >95%. Determine carboxyhemoglobin levels and administer 100% oxygen until carboxyhemoglobin levels are normalized.
There are several tests to assess circulation in a burn injury patient.
If the heart rate is >120 bpm, there are 3 potential causes: shock, other trauma and inadequate pain management.
Shock – insert 2 large bore IV lines and use boluses of Ringer’s solution to obtain a radial pulse.
Other trauma – evaluate the patient further.
Inadequate pain management – optimize analgesia according to the WHO pain ladder. Most burn injuries are extremely painful, so you should evaluate the need for intravenous strong opioids early on. If strong opioids are not available, consult the local protocols to find the most adequate alternative medication.
If the arterial blood pressure <90mmHg, shock should be suspected. If this is the case:
- Check the blood pressure in relation to pulse rate.
- Consider fluid resuscitation using boluses of Ringer’s solution.
- Assess the central capillary refill (CR) and the peripheral CR (all extremities).
- For circumferential burns on extremities, use the other corresponding limb for comparison. An escharotomy may be needed.
- Stop any bleeding by applying direct pressure.
- Take blood by inserting 2 large bore IV lines. Analyze the blood for:
- Full blood count
- Urea, creatinine and electrolytes
- Liver function tests
- Coagulation factors
- Carboxyhemoglobin levels and/or toxicology tests if indicated
- Blood type and cross match
- Assess the patient for any early clinical signs of shock. Appearance of clinical signs of shock in burn patients is usually due to a cause other than the burn. Signs of shock include:
- Pale, cool and clammy skin – occurs at loss of 30% of blood volume
- Rapid breathing
- Mental obtundation – occurs at loss of 50% of blood volume
Disability, neurological deficits & gross deformity
Evaluate the patient’s mental status using the Glasgow coma scale. A Glasgow Coma Scale score of <8 is an indication for intubation. An alteration in mental status may be caused by:
- Cyanide intoxication
- Head trauma
Examine the pupillary light responses. The pupils should be equal, round and reactive to light.
Glasgow Coma Scale
|Open to verbal command||3|
|Open to pain||2|
|No eye opening||1|
|No verbal response||1|
|Withdrawal from pain||4|
|Flexion to pain||3|
|Extension from pain||2|
|No motor response||1|
Exposure & environmental control
- Remove all clothing from the patient, including diaper, jewelry, contact lenses and any other accessories, to prevent a tourniquet effect.
- Perform a head-to-toe examination of the patient for associated injuries.
- Log roll the patient in order to visualize the posterior surface.
- Check the body temperature and ensure that a warm environment is maintained using active warming if necessary. Burn patients are at risk of hypothermia.
- Assess the extent of the burn injury using the methods of estimation. It is important to estimate the depth as well as the extent of the burn.
Remember: All resuscitation formulas provided are used as a guide.
Patients should be assessed frequently, with individual adjustments made to maintain adequate organ perfusion.
- Administer fluids intravenously to adults with burns ≥15% TBSA. Administer fluids according to the Modified Parkland formula: 3ml Ringer Solution x weight (kg) x %TBSA burned.
- Give half of the calculated volume in the first 8 hours, beginning from the time of the burn injury and not from the time administration of fluids is commenced.
- Give the other half over the next 16 hours, i.e. over 8-24 hours post-injury.
- Measure urine output to assess the efficacy of fluid resuscitation. This is the most important way of monitoring the adequacy of fluid resuscitation but is only possible with an indwelling urinary catheter (IDC). The urine output should be at least 0.3-0.5 ml/kg/hour = 30-50 ml/hour in adults (the values are different for children).
- If the urine output is inadequate, administer extra fluids via boluses of 5-10 ml/kg and/or increase the volume of fluid to be administered within the next hour to 150% of the planned volume.
There are additional considerations when calculating fluids for children. If your patient is a child, see Primary survey in children: ABCDEF method.
Hemoglobinuria is an early complication of extended full thickness burns. Red blood cells are destroyed rapidly, releasing free hemoglobin into the plasma. This free hemoglobin is then excreted in the urine.
Treat promptly using fluids to increase urine output to 1-2 ml/kg/hr.
Myoglobinuria is usually associated with rhabdomyolysis or muscle destruction. It may occur as a result of electrical burns, electrocution, blunt trauma or ischemia from compartment syndrome.
Treat promptly using fluids to increase urine output to 1-2 ml/kg/hr.
Venous cutdown or intraosseous fluid therapy
Consider a venous cutdown or intraosseous fluid therapy when veins are collapsed due to severe dehydration and standard peripheral or jugular intravenous access cannot be obtained.
Select the method according to the preference of the medical team and the equipment available.
For intraosseous infusion, the needle can be inserted into the anteromedial aspect of the proximal tibia. If intraosseous infusion is unsuccessful, a venous cutdown can be performed into the greater saphenous vein, 1cm proximal to the medial malleolus.
Oral fluids may be indicated in certain situations, including those where:
- No IV or intraosseous access can be obtained
- Only oral administration is practical
- The alternative is no fluid resuscitation
Patients should drink liquids that are typical of their normal diet, to the equivalent of 15% bodyweight per 24h for 2 days. They must ingest 5g tablets of table salt (or equivalent) for each liter of oral fluids consumed.
Oral rehydration solution (ORS) is also commonly used to replace fluid and electrolyte loss, when intravenous rehydration is unavailable. When a patient is unable to drink, ORS can be administered through a nasograstric tube.
Remember tetanus prophylaxis
Additional initial management and diagnostics
Patients with major burns are at high risk of gastroparesis. To stabilize the gastrointestinal system, insert a nasogastric tube for adults with burns >20% TBSA and children with burns >10% TBSA. This prevents gastric dilatation, vomiting and subsequent aspiration.
Pay attention to adequate pain management in the acute phase.
Given that most burn injuries are extremely painful, provide opioid analgesia intravenously, if available. Administer morphine at a starting dose of 0.05-0.1mg/ kg of bodyweight and subsequently titrate, dosing every 3-5 minutes. The final dose is determined by the patient’s response.
If morphine is not available, use the best local treatment options for effective pain management for burn victims in your facility.
Avoid the use of prophylactic systemic antibiotics for acute burns, as there is no supporting evidence for their use and it may contribute to antibiotic resistance.
As an exception, only for communities where streptococcal infection is widespread, prophylaxis may be given for 24 hours.
Late presentation with an active infection requires adequate treatment according to local protocols.
Further diagnostic tests may be performed as follows:
- ECG for all electrical burns or for patients with pre-existing cardiac conditions.
- X-Ray assessment, depending on the mechanism of trauma and clinical findings.
- Sonography (FAST scan: Focused Assessment with Sonography for Trauma) of the abdomen and cardiac windows, depending on the mechanism of trauma and clinical findings.