Primary Survey
The Primary Survey is the critical first step in the “initial assessment” of a seriously injured patient. It provides a quick and efficient way to identify if the patient has a life-threatening injury. Burn management should begin simultaneously.
A-B-C-D-E
Use the acronym A B D C D E for a systematic approach to the primary survey. The primary survey is a rapid primary evaluation determining the need for resuscitation of vital functions, with a more detailed secondary survey that follows.
Airway
Airway stability should be assessed rapidly in burns involving facial or suspected inhalation injuries, particularly in the early period following injury when the airway is at risk of obstruction due to swelling of the oropharynx and soft tissues of the neck. It is important to identify early those who may require intubation as it becomes increasingly difficult with the development of oedema, especially once fluid resuscitation has commenced which cascades the swelling.
Airway management manoeuvres such as intubation are not without risk with significant complications reported in the literature.
Key steps
- Does the patient respond appropriately to a question?
- Look for signs of airway obstruction (stridor, use of accessory muscles, paradoxical chest movements).
- Listen for any upper-airway noises and breath sounds.
Suspect inhalation injury if:
- Exposure to fire and smoke in an enclosed setting;
- Hoarseness or change in voice;
- Harsh cough; stridor;
- Burns to the face; head and neck swelling; inflamed oropharynx
- Singed nasal hair, eyebrows or eyelashes;
- Soot in the saliva, sputum, nose or mouth.
A patient with a history or signs suggestive of inhalation injury requires repeated airway assessment over time if they are not intubated.
Consider intubation if there are any signs of:
- Pending airway obstruction: stridor, hoarse voice; (requires urgent emergency intubation)
- Decreased level of consciousness;
- Unprotected airway;
- Airway is at risk in transit
- Uncooperative/combative patient leading to distress and further risk of injury
Breathing and ventilation
Breathing can be compromised following flame burn injury if people inhale smoke, especially in enclosed spaces. This can be life-threatening as it can cause damage to the lungs and toxic poisoning from substances such as carbon monoxide or cyanide. Deep circumferential burns of the chest or abdominal skin may also restrict chest expansion and compromise ventilation. Early assessment of breathing is mandatory to identify any life-threatening concerns that can be managed promptly.
Key steps
Administer 100% high flow (15 L/min) humidified oxygen via a mask or endotracheal tube.
A patient who is not breathing should be intubated and ventilated.
Assess respiratory rate, effort, breath sounds and O2 saturation. Look for signs and symptoms of inhalation injury and signs of deterioration.
Expose the chest and ensure that chest expansion is adequate and bilaterally equal.
Deep circumferential burns of the chest or abdomen can restrict chest expansion, limiting respiratory excursion and compromising ventilation. Burnt skin loses its elasticity quickly in deep burns, which can have a tourniquet effect when combined with rapidly accumulating underlying burn oedema. Respiratory insufficiency or ischemia of an extremity is a risk.
An escharotomy may be required. Escharotomy is a high-risk procedure and should only be performed after consultation and advice from ARV and the appropriate burns service.
Consider carbon monoxide poisoning in patients who sustain burns in an enclosed area. Carbon monoxide has a 280 times greater affinity for haemoglobin than oxygen does.
Oxygen administration is pivotal increasing the gradient for oxygen binding to hemoglobin, so that unbound CO can be exhaled through the lungs. Oxygen saturation is an unreliable oxygenation parameter in patients with carbon monoxide poisoning. The machines interpret carbon monoxide as oxygen giving a false positive reading when the patient can be profoundly hypoxic, so oxygen should be given regardless of the oxygen saturation.
Assess for symptoms of high COHb levels which include a history of altered consciousness associated with the accident, the presence of neuropsychiatric abnormalities, the presence of cardiac abnormalities and a cherry pink appearance to the skin. COHb blood levels should be taken in the secondary survey.
Circulation with haemorrhage control
Early assessment of circulation is mandatory to identify any life-threatening concerns such as haemorrhage which must be managed promptly.
Key steps
Stop with direct pressure.
Inspect for any signs of haemorrhage and apply direct pressure to any external wounds. Haemorrhage is rare in isolated burn injuries, but in multi-trauma burn injuries, consider the potential for internal bleeding, which may lead to shock.
This will provide an assessment of the current state of the circulatory system.
Insert two large-bore peripheral intravenous (IV) cannulas, preferably through non-burnt tissue. Use central or intraosseous insertion access if the equipment/skills are available and peripheral access is difficult.
Commence fluid resuscitation as indicated for burns greater than 20% TBSA in adults and 10% in children.
Assess the circulation of the peripheries and trunk, especially distal to the burn wound if circumferential burns are present. Elevate the affected limb to help minimise swelling and improve blood flow. Poor perfusion may indicate the need to perform an escharotomy.
Disability
A rapid neurological assessment should occur as a part of the primary survey to assess the conscious state. Inadequate oxygenation caused by smoke inhalation and toxins may affect the conscious state.
Key steps
Perform a rapid neurological assessment using the AVPU mnemonic:
A – Alert
V – Responding to Verbal stimuli
P – Responding to Painful stimuli
U – Unresponsive
Examine whether pupils are responding appropriately to light.
An altered level of consciousness indicates the need for repeated evaluation of the patient’s oxygenation, ventilation, and perfusion status. A comprehensive Glasgow Coma Scale will be completed as a part of the secondary survey.
Rule out metabolic cases of altered consciousness, such as diabetes. Ensure that any alterations in level of consciousness are not related to a metabolic cause.
Exposure and environment control
Exposure aids in early recognition of injuries, particularly in patients unable to communicate. People with severe burn injuries can lose heat quickly and efforts should be made to minimize heat loss to avoid the detrimental effects of hypothermia.
First steps
Removing clothing and exposing the patient will allow for a quick head-to-toe examination and early recognition of injuries. Jewellery should be moved, take special note of rings and bracelets which can have a tourniquet effect if the surrounding skin is burnt.
Examine the patient from head to toe for burns and other injuries, and log roll to check posterior surfaces. Inspect for concomitant injuries and get the first estimation of burn %TBSA.
Keep the patient warm and cover again ASAP to minimise heat loss.
Efforts should be made to minimise heat loss due to the high risk and detrimental effects of hypothermia for severe burns patients secondary to the loss of skin integrity. Cover the patient with warm blankets, warm the environment, and administer warm IV fluids.
Whilst performing the head-to-toe assessment expose only those areas of the body being inspected and keep other areas covered to preserve warmth, and cover again as soon as possible.