The primary survey is the initial assessment and management of a trauma patient.
Use a systematic approach based on <C> ABCDE(10, 11) 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 multisystem injuries.
Catastrophic haemorrhage
Assess for catastrophic haemorrhage
- Identify any large volume external blood loss.
- Provide immediate management as required, consider; direct pressure, haemostatic dressings and torniquets.
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.
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 (use of accessory muscles, paradoxical chest movements, see-saw respirations).
Listen for any upper-airway noises, breath sounds. Are they absent, diminished, or noisy?
Assess for displaced dentures, especially in the older persons cohort.
Assess for inhalation injury
Early intubation is indicated with inhalation injuries. Suspect an inhalation injury if there has been any history of(12):
- 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,
- 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 consciousness(12).
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 whilst avoiding neck extension to protect the C-spine.
Suction the airway if excessive secretions are noted or if the patient is unable to clear their airway independently.
Insert an oropharyngeal airway (OPA) if required.
Caution: Nasopharyngeal airways (NPA) should not routinely be inserted in patients with a head injury in whom a base of skull fracture has not been excluded(13). In the setting of airway obstruction, or failure to oxygenate, then an NPA can be inserted if delay to definitive airway management.
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.
Breathing and ventilation
Assessing for adequate ventilatory effort is essential.
Administer high flow oxygen and record the oxygen saturation (SpO2)
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
Be mindful that thoracic injuries may have also occurred.
Count the patient’s respiration rate and note the depth and adequacy of their breathing.
Auscultate the chest for breath sounds 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).
Circulation with haemorrhage control
Assess circulation and perfusion
Check the heart rate and blood pressure.
Inspect for any signs of external haemorrhage and apply direct pressure to any wounds.
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.
Disability: neurological status
Assess level of consciousness
Complete an AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive). A more detailed neurological assessment using the GCS will be performed in the secondary survey.
Inadequate oxygenation as well as inhalation of smoke and toxins may lead to a decreased level of consciousness.
Check pupillary response.
Test blood sugar levels
Ensure that any alterations in level of consciousness are not related to a metabolic cause.
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.