Primary Survey

Use a systematic approach based on the ABCDE6 survey to assess and treat an acutely injured patient. The goal is to manage any life-threatening conditions and identify any emergent concerns, especially in a burns patient who may present with other concomitant polytrauma complications.


 Airway with cervical spine protection

The patient’s airway is at significant risk in severe burns injuries, especially where there is involvement of facial or inhalation injuries. It is important to quickly identify those who may require intubation. Intubation can become increasingly difficult as swelling progresses in the first few hours following an injury, especially once fluid resuscitation has commenced. Early airway management is essential as signs of impending airway obstruction may not be immediately obvious.

Severe airway burns
Image used with permission from the Alfred Hospital


Assess for airway stability

Attempt to elicit a response from the patient.
Look for signs of airway obstruction (stridor, use of accessory muscles, paradoxical chest movements and see-saw respirations).
Listen for any upper-airway noises and breath sounds. Are they absent, diminished or noisy?

Assess for inhalation injury

Early intubation is indicated with inhalation injuries. Suspect an inhalation injury if there has been any history of:

  • exposure to fire and smoke in an enclosed setting,
  • hoarseness or change in voice,
  • harsh cough,
  • burns to the face,
  • head and neck swelling,
  • singed nasal hair, eyebrows or eyelashes,
  • or soot in the saliva, sputum, nose or mouth.

    Assess for an inflamed oropharynx.

    Secure the airway if necessary (treat airway obstruction as a medical emergency)

    Standard indications for intubation should be followed including but not limited to shortness of breath, wheezing, stridor, hoarseness, combativeness, or a decreased level of consciousness7.
    Contact should be made with the major burns service as soon as is safely feasible to discuss the events surrounding the burn and the need for intubation.

Attempt simple airway manoeuvres if required

Open the airway using a chin lift and jaw thrust.
Suction the airway if excessive secretions are noted or if the patient is unable to clear their airway independently.
Insert an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA) if required.
If the airway is obstructed, simple airway opening manoeuvres should be performed, including suction, a jaw thrust or a chin lift. Care should be taken to not extend the cervical spine.
Caution: An NPA should not be inserted in patients with a head injury in whom a base of skull fracture has not been excluded.

Maintain full spinal precautions if indicated

Suspect spinal injuries in all polytrauma patients. Ensure cervical collar, head blocks and in-line immobilisation is maintained throughout patient care.

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 Breathing and ventilation

Administer high flow 100% (15 L/min) of humidified oxygen

Assume carbon monoxide poisoning in patients who sustain burns in an enclosed area. Carbon monoxide preferentially binds to haemoglobin, leading to falsely reassuring oxygen saturation levels. Oxygen administration is pivotal, regardless of the oxygen saturation recording.

Assess the chest

Count the respiration rate – elevated respiratory rates are markers of a potential inhalation injury and a warning that the patient may deteriorate.
Note the depth and pattern of respiration, and assess the symmetry of rise and fall of the chest. Remember that underlying chest injuries may also be present.
Listen to the chest and assess for any wheeze, stridor or decreased air entry.
Circumferential burns to the chest may inhibit chest wall expansion and make ventilation difficult; consider an escharotomy (see Early Management below).

Record the oxygen saturation (SpO2)

Note that SpO2 will not detect elevated carbon monoxide levels.

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 Circulation with haemorrhage control

Assess circulation and perfusion

Check the heart rate, blood pressure and neck veins.
Inspect for any signs of haemorrhage and apply direct pressure to any external wounds. Consider the potential for significant internal bleeding related to the mechanism of injury, which may lead to signs and symptoms of shock.
Insert two large-bore peripheral intravenous (IV) cannulas, preferably through non-burnt tissue. If access is difficult consider central or intraosseous insertion if the equipment/skills are available.
Commence fluid resuscitation as indicated for burns greater than 20% TBSA in adults.
Review the unburnt skin colour and check the temperature and capillary refill.
Monitor the circulation of the peripheries and trunk, especially distal to the burn wound if circumferential burns are present. Elevation of the affected limb will assist in managing swelling. Poor perfusion may indicate the need to perform an escharotomy.

If necessary, perform a FAST scan

If the patient is haemodynamically stable and there are no signs of significant internal bleeding then a FAST scan may be delayed until the secondary survey.

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 Disability: neurological status

Assess level of consciousness

Inadequate oxygenation as well as inhalation of smoke and toxins may lead to a decreased level of consciousness.
Perform an initial GCS (Glasgow Coma Scale) / AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive); check the pupillary response.

Test blood sugar levels

Ensure that any alterations in level of consciousness are not related to a metabolic cause.

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 Exposure/environmental control

Remove the patient’s clothing and any jewellery in order to prevent any further heat injury and to be able to fully assess all areas of the body.
In suspected chemical burns, clothing may remain contaminated. Inappropriate handling may expose the patient to further injury as well as the care provider. Wear appropriate PPE.
It is important to minimise heat loss for severe burns patients due to the risk of hypothermia secondary to the loss of skin integrity. It is important to monitor the patient’s temperature and keep them in a warm environment with warm IV fluids.

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