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Chapter 3. Initial Assessment ofBurn Patient
F . When assessing the abdomen, significant distention in
the presence of oliguria should raise concern for abdominal compartment syndrome. This syndrome can be confirmed with bladder
pressure measurements and treated with decompressive laparotomy,
as illustrated in this patient
95
Extremity
Evaluation of the extremities centers on excluding non-burn
injuries and monitoring peripheral perfusion. Radiographs
can be helpful to identify any extremity fractures. Fractured
and burned extremities should initially be stabilized with
splints. Elevating the affected extremities may help reduce
swelling. The evolving need for escharotomy should be carefully examined by frequently assessing extremity temperature, pliability, voluntary motion, pain with passive motion,
named vessel pulsations, and low-pressure blood flow with
the use of capillary refill and Doppler signals in the digital
vessels (Fig.3.7). In instances when escharotomy does not
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M. A. DePamphilis and R. L. Sheridan
F . In patients with deep circumferential burns, edema may
form beneath eschar, which can result in vascular comprise and
impaired function. During the initial assessment, clinicians should
identify any burn wounds that require close monitoring or decompression by escharotomy. Promptly and properly performed escharotomy will typically result in immediate improvement in perfusion,
as demonstrated in this example of an upper extremity (including
hand and digits) escharotomy. Use of electrocautery and topical
clotting agents can help control bleeding
restore peripheral perfusion, fasciotomy should be considered; most common with very deep burns or high-voltage
electrical injuries (Fig.3.8).
Evaluation oftheBurn Wound
A fundamental aspect of initial burn care is knowing how
to accurately evaluate a patient’s burn injuries. Burn
wounds are highly quantifiable, and these calculations are
critical as they will help guide resuscitation requirements,
referral determination, and prognosis. Focus should be
shifted to examining the burn wounds only after the
patient’s overall condition has been thoroughly assessed
and stabilized. Important burn wound assessment measures
include (1) depth, (2) extent, (3) circumferential components, and (4) infectious colonization.
Chapter 3. Initial Assessment ofBurn Patient
F . In instances of very deep burns or high-voltage electrical
injury, edema may collect within extremity muscle compartments
that can result in limb ischemia. In these cases, escharotomy alone
may not be sufficient, requiring fasciotomy to release tension and
restore perfusion. Fasciotomies can be performed through the initial
escharotomy incisions, as portrayed in this lateral view of a decompressed lower extremity that sustained deep flame burns
97
Burn wound depth (or the propensity of a burned area to
heal) drives surgical and non-surgical care planning (Fig.3.9).
Burn depth follows a classification system that categorizes
the degree of tissue penetration from superficial to fullthickness (more commonly known as first-degree to fourthdegree) (Figs.3.10 and 3.11). Burn wound extent influences
resuscitation and transport decisions and is calculated by
determining the percentage of total body surface area
(%TBSA) that is involved in a burn. Superficial burns (firstdegree burns) are the most benign and should not be included
in %TBSA calculations.
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M. A. DePamphilis and R. L. Sheridan
Level of Burn Injury Clinical Characteristics
Burn
Thickness
Superficial
Superficial
partial-
thickness
Deep
partial-
thickness
Full-
thickness
Common
Classification
First-degree Epidermis only Pink to red; dry No Yes
Superficial
second-
degree
Deep second-
degree
Third-degree,
fourth-degree
Depth of
Involved Tissues
Papillary dermis
(entire epidermis
and superficial
dermis)
Reticular dermis
(entire epidermis
and deeper
portions of the
dermis)
Entire cutaneous
layer (third-
degree), and may
extend through
subcutaneous
tissue involving
fascia, muscle,
and/or bone
(fourth-degree)
Color and
Texture
Homogeneous
pink to red; wet
Mottled red and
white; dry
Waxy white,
brown, and/or
black; leathery,
charred, and/or
inelastic; dry
Blisters
Yes
Yes or
No
No No
Intact Hair
Follicles
Yes
No, hair
removes
easily
Capillary
Refill
Blanches
quickly
with
pressure
Blanches
with
pressure
Reduced
blanching
with
pressure
Does not
blanch
Sensation
Hypersensitive;
painful
Hypersensitive;
very painful
Intact but
decreased
sensation;
variable in pain
Insensate; any
pain is typically
caused by
surrounding
burned tissue
of lesser depth
F . A summary of the clinical characteristics at each burn
depth level
F . An example of a superficial partial-thickness contact
burn to the hand. Note the characteristic blister and fluid formation.
When blisters are removed, the underlying wound is pink, wet, and
hypersensitive
Chapter 3. Initial Assessment ofBurn Patient
F . An example of a deep full-thickness burn to the upper
extremity. Note the charred and dry surface appearance with areas
of thick, black eschar
99
Several clinical evaluation methods exist to help guide
%TBSA measurements including the “Rule of Nines” [14],
the “Rule of Palms” [15], and the Lund-Browder Chart [16].
The “Rule of Nines” is the quickest guide as it divides anatomic regions into distinct sections that are equivalent to
multiples of 9% TBSA.However, this method is usually the
most inaccurate and should not be used for children because
it fails to account for different body size ratios. The “Rule of
Palms” considers the palmar surface of the patient’s hand
(including digits) as 1% TBSA and is especially advantageous
for irregularly shaped burns that are not confluent. Overall,
the Lund-Browder chart is the most preferred method
because it accounts for changes in body proportions across
different age groups, making it the most reliable. For the
Lund-Browder method, a 2D diagram that mimics the patient
is utilized to shade in the burn and then an associated table
helps to calculate the %TBSA. A Lund-Browder diagram
should be carefully completed and documented for all
patients with major burns.
Unfortunately, in many cases, burn wound depth and extent
are difficult to ascertain on initial examination, especially for
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M. A. DePamphilis and R. L. Sheridan
F . Burn depth can be difficult to ascertain on initial encounter. In some cases, variable burn depth may not be apparent until after
initial wound cleansing and debridement. Note the scattered and surrounding areas of partial-thickness injury (white arrows) within this
majority full-thickness burn wound (black arrow)
those who are non-burn specialists (Fig. 3.12) [17]. For any
questionable burn wounds, a non-burn provider should consider consulting by telemedicine with a burn specialist to help
make an accurate wound assessment and craft an appropriate
plan [18]. Even by specialists, burn wounds are often underestimated in depth and overestimated in extent at initial encounter [19, 20]. Therefore, there have been ongoing efforts to
develop non-invasive technology to precisely determine extent
and depth of a burn wound. Various wound mapping applications are currently available to assist with extent determination
[21, 22]. A number of adjuncts have been devised to help esti-
mate burn wound depth including fluorescence [23], thermography [24], ultrasound imaging [25], and laser Doppler imaging
[26]. Each of these technologies has weaknesses and none have
become standard of care. If used, these adjuncts should supplement, not replace, clinical evaluation.
In addition to depth and extent examination, burn wounds
that have circumferential nature should be identified, closely
monitored, and decompressed with escharotomy when neces-
Chapter 3. Initial Assessment ofBurn Patient
101
sary (see Burn Patient Assessment section). Pertinent locations include the extremities, torso, abdomen, and neck.
Wounds should also be inspected for signs of infection including unusual color, drainage, or odor. Suspicions of infection
should be confirmed with wound and blood cultures.
Triage, Referral, andTransfer Determination
At the conclusion of the secondary survey, a determination
needs to be reached as to who should be treated as an outpatient, who should be treated in a local general hospital, and
who should be referred to a specialized burn center. It is as
important to properly assess a burn patient as it is to recognize those wounds and patients that require specialty care
[27]. Appropriate and early referral determination can have a
large impact on optimizing a patient’s outcome and reducing
costs [28, 29].
Treatment of minor burns can be successfully achieved
through close outpatient clinic follow-up (predominately
uncomplicated and small superficial to superficial partialthickness burns) (see Chap. 17). Although, there are some
circumstances when hospital admission for minor burns is
acceptable. Moderate burns may be treated by an experienced physician as an inpatient at a general hospital or can be
referred to a burn center (generally partial-thickness to small
full-thickness burns). If the burns are major (large or deep
burns, any special type of burn, and any burn complicated by
inhalation injury, circumferential nature, critical area
involvement [face, hands, feet, genitalia, perineum, or major
joints], associated non-burn injuries, preexisting conditions,
or the patient’s age), then the patient should be transferred to
a specialized regional burn care facility. The American Burn
Association has promulgated guidelines that outline specific
burn injuries that typically require specialty burn center
referral [7].
Using a “common sense” approach when contemplating
whether a patient should be transferred is always advisable,
honestly considering local resources and care team expertise.
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M. A. DePamphilis and R. L. Sheridan
Regardless of disposition decision, detailed coordination is
essential. Frequent and ongoing communication should be
facilitated between the referring and receiving centers. When
in doubt, the best practice is to consult a specialist at a local
burn center to help guide the decision process [18].
Tertiary Survey
The last phase of the initial assessment for a burn patient is
the tertiary survey, which occurs over a period of 24–72 h
post-admission. The tertiary survey is applicable to patients
that cannot be transferred within 24h or if a determination
has been made to continue treatment at a general hospital. At
this point in care, fluid resuscitation and initial wound management should already have commenced (see Chap. 4). The
main focus of this stage is reevaluation, accomplished through
both serial physical examination and one final thorough
patient assessment. For serious burns, there should be an
ongoing effort to reasonably exclude all potential injuries.
The importance of this phase cannot be underestimated [30].
Several issues that may have been overlooked or appear
subtle during previous stages of the initial assessment can
quickly become catastrophic and life threatening over time.
In addition to regularly monitoring the patient’s condition,
the burn wounds should be serially examined. Progressive
edema formation beneath eschar or fascial compartments is
common in burn patients and is especially prominent
throughout the initial resuscitative period for those with
large, deep, or circumferential wounds. Failure to identify atrisk compartments can result in impaired ventilation or irreversible tissue necrosis. Therefore, the evolving need for or
the effectiveness of previous decompression should be frequently assessed throughout initial care. Also, a continuous
effort to reevaluate the burn wounds for depth and extent
should be instituted. Burns are dynamic and may continue to
progress for days after injury; especially common with chemical and electrical injuries, which are notorious for underesti-
Chapter 3. Initial Assessment ofBurn Patient
mation. This step is essential because it may trigger
adjustments to initial resuscitation requirements or initial
management strategies.
Another necessary component of the tertiary survey is a
planned meticulous head-to-toe patient examination supplemented with focused diagnostic testing. The main objective of
this repeat thorough assessment is to identify concomitant
injuries that were either minor or missed during the chaos of
previous stages of the initial assessment. Common examples
that clinicians should be on the lookout for are any extremity
fractures, small lacerations of the scalp, subtle eye injuries, or
abdominal visceral injuries. Taking the time for this additional assessment is critically important as early discovery of
these injuries can have a significant impact on minimizing the
patient’s suffering and long-term morbidity [31].
103
Prehospital andInitial Assessment
Considerations forSpecial Situations
Chemical Injury
Chemical burn injuries (see Chap. 14) are typically caused
from exposure to strong acid or alkalis [32]. The first priority
of prehospital care should be ensuring that all providers have
the appropriate equipment to protect against harmful contact
with the involved agents. All contaminated clothing should be
carefully removed from the patient. If there is any residual
dry chemical or powder agent, it can be brushed away.
Following mechanical removal, or for liquid agents, the
affected areas should be irrigated with copious amounts of
water for 30 min to dilute the contaminating agent. In the
majority of cases, attempts to neutralize chemicals are contraindicated as the neutralization reaction may produce heat as
a by-product which can inflict further tissue damage.
Throughout the prehospital management process, special
attention should be given to limit spread of the agent to unaffected regions.
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M. A. DePamphilis and R. L. Sheridan
There are specific components of the initial assessment
that are essential for patients who are present with chemical
injuries. The clinician must obtain a focused history to identify the substance(s) involved, quantity and concentration of
the agent(s), and the duration of exposure as these may provide insight to the severity of injury. Poison control centers
should be consulted if there is a suspected risk of systemic
toxicity. In particular, hydrofluoric acid injuries may result in
dangerous hypocalcemia [33]. For all chemical exposures, the
potential for fume inhalation or ocular injury should be
assessed during the primary and secondary survey. For these
injuries, it is also especially important to perform serial
wound examination as chemical burns are insidious for progressing over prolonged periods. Consequently, all chemical
burns should be considered deep partial-thickness or fullthickness during initial evaluation until proven otherwise.
Depending on the initial assessment findings, chemical burns
meet the criteria and should typically be referred to a specialized burn center.
Cold Injury
Cold induced injuries (frostbite) (see Chap. 24) typically
occur to the distal extremities or exposed areas of the face
to those with decreased ability to respond to cold or those
involved in expeditions (Fig.3.13) [34]. During the initial
assessment, patients with cold injuries should always be
evaluated for hypothermia and managed accordingly. The
involved frozen tissues should be rewarmed with water that
is at 37–40°C.However, the affected regions should not be
rewarmed if there is a risk of refreeze (in instances when
rewarming is performed during prehospital care) as freezethaw- refreeze may result in worse injury. A cold
injury- specific wound evaluation of the secondary survey
should assess for the following clinical features as they may
provide insight to the stage of injury: burning, numbness, or
pallor followed by erythema and discomfort in response to
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