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Chapter 3
Initial Assessment
ofBurn Patient
MatthewA.DePamphilis andRobertL.Sheridan
Introduction
One of the first documented initial assessments of a burn
patient was by the Harvard anesthesiologist Henry
K.Breecher in description of his first impression when caring
for victims of the Coconut Grove Fire [1] in Boston,
Massachusetts on November 28, 1942 [2]. This historic tragedy led to a new era of burn research focused on optimizing
patient survival and long-term outcome. Since then, a four
M. A. DePamphilis
Boston Shriners Hospital for Children, Boston, MA, USA
Boston University Chobanian and Avedisian School of Medicine,
Boston, MA, USA
Division of Burns, Massachusetts General Hospital,
Boston, MA, USA
e-mail: mdepamph@bu.edu
R. L. Sheridan (*)
Boston Shriners Hospital for Children, Boston, MA, USA
Division of Burns, Massachusetts General Hospital,
Boston, MA, USA
Department of Surgery, Harvard Medical School,
Boston, MA, USA
e-mail: rsheridan@mgh.harvard.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_3
85
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M. A. DePamphilis and R. L. Sheridan
clinical phase approach to burn care has been formulated and
specialized burn centers have been established [3]. The first
phase of burn care encompasses initial assessment, triage, and
fluid resuscitation, which is typically completed over the first
72hours post-injury. A methodical initial assessment accompanied with an effectively implemented triage and referral
system can help shorten hospital stay, reduce costs, and most
importantly, have a long-lasting impact on a patient’s recovery. In this chapter, the authors will describe how to perform
the initial assessment of burn care in terms of careful evaluation of the patient, thorough assessment of the burn wounds,
and appropriate determination of when specialty referral is
needed. Basic principles of prehospital care and initial assessment considerations for special situations are also reviewed.
First Aid andPrehospital Considerations
The main priorities of prehospital care include removing the
patient from the burn source, addressing any immediate lifethreatening conditions, maintaining normothermia, and appropriately transporting the patient to a medical facility (Fig.3.1).
On arrival to the injury site and prior to initiating care, emergency responders should take a moment to assess the scene,
ensuring that it is safe to approach and that they will not be
putting their own lives at risk. If the patient is still at the burn
source, then a provider should cautiously extricate the patient
and stop the burning process. The patient’s clothing should be
removed to prevent further burn injury. Any belts or jewelry
should also be removed as they may produce a tourniquet-like
effect resulting in vascular compromise with onset of edema.
During prehospital care, first responders have the option
of applying cool water (15–25 °C) to the burn wounds in
attempt to limit the extent of burn injury and reduce pain.
This practice is a topic of controversy because of the risk of
inducing systemic hypothermia due to impaired thermoregulation in burn patients. Generally, immediate cooling is only
advised in instances when the providers arrive within a few
minutes of injury for minor burns less than 10% of the body
surface. Ice or icepacks should not be used as a topical cool-
Chapter 3. Initial Assessment ofBurn Patient
87
First Aid and Prehospital Measures Comments and Considerations
Extricate the patient and stop the burning
Remove the patient’s clothing and jewelry
Immediately cool the burn wounds by
Assess the patient and address any life-
Obtain and document a detailed history
Maintain the patient’s body temperature
process
application of water
threatening conditions
Appropriately triage and transport
● Always first assess scene safety
● Carefully approach with the necessary protective equipment
● This step can help prevent further injury
● Do not attempt to remove any material that has adhered to the
patient’s skin, cut around it
● The patient’s condition and risk of hypothermia must be considered,
typically cooling is only beneficial within minutes of minor burns
● Water should be 15°C to 25°C and applied briefly (3-5 minutes)
● Ice or icepacks should not be used
● Primary survey (ABCs of trauma management)
● Secondary survey (when applicable)
● Especially related to the events and circumstances of injury from
personnel who will not be available to the receiving facility
● Emergency providers should clearly document all interventions
administered
● Consult regional protocols: most patients are first transported to the
nearest emergency department for stabilization, some patients may
be eligible for direct burn center admission
● Notify family members of the transport decision (when applicable)
● Fluid administration may be necessary for transport times greater
than 1 hour
● Patients with burn injuries are at high risk for hypothermia
● The transporting vehicle should be heated
● The patient should be wrapped in dry, clean, sheets or blankets
● Wet dressings or any topical home remedies should not be used
F . A checklist of important measures that first responders
should address during prehospital care of a burn patient
ing measure. During transport, the patient should be kept in
a warm and dry environment to prevent hypothermia.
Transporting vehicles should be heated and the patient
should be wrapped in dry, clean, sheets, and blankets. Wet
dressings should be avoided and may even be hazardous due
to the significant risk of hypothermia and infection.
Standard prehospital triage of a burn patient typically follows a system of first transporting the patient to the best available care facility for assessment, stabilization, and subsequent
referral determination. Appropriate options are often the
nearest emergency department or local general hospital. There
are some instances where an amalgamation of factors such as
age, past medical history, burn severity, and mechanism may
warrant direct admission to a specialized burn center.
Initial Assessment
At some point in their career, non-burn specialists may be
called upon to perform an initial assessment on a patient that
sustained a burn injury. Most commonly, patients will present
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M. A. DePamphilis and R. L. Sheridan
to a non-burn specialist with superficial wounds that are
uncomplicated, necessitating a non-intensive initial assessment. However, in some instances, a patient may present with
severe burns accompanied with serious multisystem injury
requiring high-level evaluation. Following an organized
approach to the initial assessment with attention to certain
burn-specific issues, as described in this section, can have a
profound impact on the patient’s survival and long-term
recovery [4, 5].
Primary Survey
The initial assessment of a burn patient begins with the primary survey, which is similar to that of a trauma patient. It
should follow the format that has been developed by the
American College of Surgeons Committee on Trauma and
taught in the Advanced Trauma Life Support program [6].
The American Burn Association has also established guidelines that are covered in the Advanced Burn Life Support
courses [7]. The main principle of the primary survey is to
identify and immediately address life-threatening injuries
related to airway, breathing, circulation, disability, and
exposure (the ABCs). There are some salient burn-specific
circumstances that should be highlighted.
Airway security is of utmost importance and can be especially challenging to maintain in burn patients (see Chap. 5)
[8, 9]. Inhalation injury or burns to the face and neck can
threaten airway patency and breathing, sometimes requiring
prophylactic endotracheal intubation if obstructive mucosal
edema evolves. This is especially true for young children as
they have proportionally smaller airways that can be rapidly
occluded by progressive edema [10]. Indications that should
raise concern for impending airway loss include: (1) a history
of smoke exposure or enclosed space entrapment, (2) progressive stridor, wheezing, or hoarseness, (3) singed nasal
vibrissae, (4) soot in the airway, (5) carbonaceous debris in
the mouth, pharynx, or sputum, or (6) hypoxia. Following
Chapter 3. Initial Assessment ofBurn Patient
F . Examining the airway is an essential component of the
initial assessment for a burn patient. Patients with facial burns or
suspected inhalation injury may require intubation. Following intubation, it is crucial to properly secure and frequently monitor the
endotracheal tube as extensive airway edema formation can make
reintubation increasingly difficult. A twill-tie harness system overprotective pads, as assembled for this patient, can reliably secure the
endotracheal tube and reduce injury to the oral commissures
89
intubation, it is critical to properly secure and monitor the
endotracheal tube, which can be reliably accomplished with a
harness system using umbilical ties or other commercial
devices (Fig. 3.2). Improper management of a threatened
airway or an unplanned extubation can be severely problematic as evolving edema may complicate intubation or reintubation efforts [11].
Following airway control, effective breathing and symmetrical air entry should be assessed. Any thick or circumferential
eschar considerably hindering chest wall compliance may
require escharotomy to improve ventilation. Bronchospasm
can typically be treated with nebulized β-adrenergic agonists.
Achieving reliable vascular access and beginning initial fluid
infusion are important priorities for patients with visibly large
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M. A. DePamphilis and R. L. Sheridan
F . Obtaining stable vascular access is of critical importance
for patients with severe burns. When central or peripheral access is
difficult to secure, intraosseous access is a sufficient alternative that
can support initial resuscitation. In emergencies, placing the device
through burned skin is acceptable. These devices should be removed
or replaced at an unburned site when appropriate
burns. The optimal access option is central venous line placement through intact skin. In emergencies, placing peripheral or
intraosseous lines through burns is acceptable (Fig.3.3). As the
final component of the primary survey, it is imperative to perform a quick neurological assessment for all burn patients to
assess level of consciousness (AVPU scale [“Awake, Verbal,
Pain, Unresponsive”] and Glasgow Coma Scale).
Burn-Specific Secondary Survey
Obtaining aBurn-Specific History
One of the priorities of the secondary survey should be eliciting and documenting a detailed history from the patient
(when possible) concerning the patient’s past medical history
Chapter 3. Initial Assessment ofBurn Patient
All Burn Paents Special Situaons
F . A checklist of the pertinent history points that should be
gathered at the beginning of the secondary survey. Significant information related to the patient’s past medical history and the circumstances of injury should be collected from all patients that present
with burn wounds. For special burn situations, there are additional
etiology-specific details that should be gathered. Thorough documentation of all relevant history information is essential
91
and circumstances surrounding the burn injury (Fig. 3.4). A
directed effort should also be made to interview any family
members or witnesses that were present at the time of injury
as well as any emergency response personnel or medical providers involved in prior care. This is a crucial component of
the initial assessment as an accurate history can provide
insight into factors that might influence burn care and management decisions.
Burn Patient Assessment
A more detailed head-to-toe assessment is an essential component of the secondary survey and should precede examination of the burn wounds. This patient assessment component
of the secondary survey is similar to that of any trauma
patient. At this stage, the patient should have a reliable air-
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M. A. DePamphilis and R. L. Sheridan
way and should be hemodynamically stabilized. Careful
assessment should identify any associated medical illness or
traumatic injury as approximately 5–7% of burn patients may
also present with non-thermal trauma [12]. Physical
examination should be supplemented with appropriate use of
laboratory testing and diagnostic imaging driven by mechanism of injury. There are some common concomitant clinical
issues that may present with burn injuries that should be
discussed.
Neurologic
A comprehensive neurological evaluation is paramount and
can become exceedingly difficult as patients with serious
burn injuries can typically enter an obtunded state over the
succeeding hours. Central nervous system trauma such as
intracranial injury or any spinal and ligamentous disruption
should be excluded. A computed tomographic scan of the
head and spine should be ordered for any mechanism that is
consistent with head injury. Toxic gas poisoning may occur in
patients with inhalation injury or a history consistent with
enclosed space exposure. Mental status abnormalities should
prompt suspicion of carbon monoxide poisoning, which can
be detected by measurement of carboxyhemoglobin levels.
Additionally, there should be an early multidisciplinary effort
to devise a strategy for safely managing the patient’s inevitable pain and anxiety (see Chap. 16). For most burn patients,
pain and anxiety are often best initially controlled by titrating
small doses of narcotic analgesics and benzodiazepines.
Ophthalmologic
An ocular examination is another necessary component of
the secondary survey. The globes should be assessed early for
injury because progressive edema and adnexal swelling will
make this challenging. Deep ocular burns resulting in corneal
epithelial loss may cause the cornea to have a cloudy appear-
Chapter 3. Initial Assessment ofBurn Patient
F . An early ocular examination is an important part of the
secondary survey for a burn patient. Although rare, deep burns to
the face and orbit may result in diffuse edema formation that can
elevate intraocular pressure and threaten vision. Critically high
intraocular pressures can be diagnosed by tonometry and decompressed by lateral canthotomy, as demonstrated in this patient. Note
the cornea’s clouded appearance, indicating serious globe burns
93
ance. More subtle ocular injuries can be detected using fluorescein staining. At this time, tarsorrhaphy is rarely necessary
as eyelid edema typically provides sufficient globe coverage.
Deep facial burns in patients with large surface area burns
and diffuse edema can be associated with vision-threatening
intraocular hypertension. In such scenarios, early ophthalmologic consultation with tonometry is indicated. If demonstrated, lateral canthotomy can immediately normalize
intraocular pressure and preserve retinal blood flow (Fig.3.5).
Otolaryngologic
The otolaryngology assessment begins with palpation of the
head, face, and neck for signs of trauma or fractures. The possibility of inhalation injury should be reevaluated through
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M. A. DePamphilis and R. L. Sheridan
physical examination of the throat and nose. Fiberoptic bronchoscopy, CT scanning, and radionuclide imaging have been
proposed as adjuncts for inhalation injury severity stratification, but in most cases diagnostic accuracy is adequate with
history and physical examination [12, 13]. When applicable,
the position and security of the endotracheal tube should be
reassessed. Although rare, the neck and face should be
examined for any deep, circumferential eschar that may
impair venous return and addressed accordingly with
escharotomy.
Chest andAbdomen
There are several objectives of the chest and abdominal secondary survey. The torso and abdomen should be examined for
any associated trauma. Inappropriate resuscitative volume
requirements may be a sign of an occult intra-abdominal injury.
Ulcer prophylaxis and nasogastric tube placement are indicated for all patients with serious burn injuries. Radiographs
can help rule out any concomitant trauma and confirm catheter or tube placement. The chest should be reassessed to ensure
adequate and symmetric ventilation. The evolving need for
chest or abdominal decompression should be evaluated. Intraabdominal hypertension can develop in patients with large
burns, diffuse anasarca, and delayed resuscitation causing
hypotension, impaired ventilation, and oliguria. In such
patients, abdominal decompression may be required to restore
hemodynamics, ventilation, and renal perfusion (Fig.3.6).
Genitourinary
In addition to documenting injury, the primary genitourinary
concern of the secondary survey is ensuring that a Foley catheter is placed for patients requiring fluid resuscitation. For
uncircumcised male patients, the foreskin should be reduced
over the bladder catheter to prevent paraphimosis as a result
of progressive edema.
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