Assessing the severity of burns and providing prompt, appropriate treatment is critical for burn patients. There are four key aspects of assessment that guide burn treatment and management: airway, breathing, circulation, and disability/neurological status. Rapidly and systematically evaluating these four domains allows clinicians to determine how severe the burn is, what interventions may be required, and what the prognosis is for the patient.
Airway Assessment
Assessing the airway is the first priority when evaluating a burn patient. Burns, particularly to the face and neck, can cause swelling that obstructs the airway. Inhalation injury from smoke or chemicals can also damage the airway. Signs of airway compromise include hoarseness, stridor, wheezing, tachypnea, dyspnea, and changes in mental status. Patients at high risk for airway issues include those with burns to the face, mouth, or neck, evidence of smoke inhalation, singed nasal hairs, carbonaceous sputum, and voice changes. Airway patency should be evaluated immediately upon patient contact. Early definitive airway management, including intubation, should be performed for any airway compromise. Fiberoptic nasal or oral intubation is preferred over nasotracheal intubation in inhalation injury, as nasal mucosa may be damaged. Regular reassessment of the airway is essential.
Breathing Assessment
After airway, breathing must also be rapidly assessed. Signs of respiratory insufficiency include increased respiratory rate, use of accessory muscles, cyanosis, diminished breath sounds, hypoxemia, and mental status changes. Inhalation injury can lead to bronchospasm, pulmonary edema, and ventilation-perfusion mismatching. Carbon monoxide and cyanide poisoning should also be considered in smoke inhalation. High flow oxygen should be provided. Early endotracheal intubation and mechanical ventilation may be required in significant respiratory compromise. Continuous pulse oximetry is recommended. Serial chest x-rays and arterial blood gases can help track respiratory status.
Circulatory Assessment
Assessing circulation involves evaluating for signs of shock and inadequate tissue perfusion. Extensive burns cause massive fluid shifts that can result in hypovolemic shock. Signs include tachycardia, hypotension, cool extremities, prolonged capillary refill, and decreased urine output. Aggressive intravenous fluid resuscitation is essential to stabilize burn shock. The Parkland formula can help guide fluid administration: 4 ml x %TBSA x kg body weight. Half is given over the first 8 hours post-burn, and half over the next 16 hours. Blood loss should also be considered in trauma. Hemodynamic monitoring through arterial and central venous catheters helps guide ongoing fluid management. Vasopressors may be needed to support blood pressure. Electrolyte levels are monitored and corrected.
Disability/Neurological Assessment
The disability/neurological assessment evaluates mental status, motor and sensory function. Alteration in consciousness may indicate hypoxia, carbon monoxide toxicity, or other injuries. Motor function should be assessed by testing muscle strength and watching for movement. Sensory testing includes light touch, pain sensation, and proprioception. Burn patients are at risk for spinal cord injury if there is burns, trauma, or electrical shock. Neurological complications like cerebral edema can also occur after major burns. Frequent neurological reassessments are key, with appropriate imaging if any deficits are found.
Other Aspects of Burn Assessment
In addition to the critical ABCD assessments above, there are other important aspects of evaluating burn patients:
- Determine total body surface area (TBSA) burned using rule of nines or palm method
- Assess burn depth (superficial, partial, full thickness)
- Identify any associated traumas
- Obtain thorough history of injury cause, smoke inhalation, loss of consciousness, tetanus immunization status
- Complete exposure and examination to find all burns
- Check for circumferential burns which can limit circulation
- Be alert for child abuse and neglect
- Order appropriate diagnostics like CBC, electrolytes, coagulation studies, chest x-ray, arterial blood gases, carboxyhemoglobin level, urinalysis
Types of Burn Assessments
There are various assessment tools and scores utilized in burn care:
American Burn Association (ABA) Burn Assessment
The ABA burn assessment covers airway, breathing, circulation, neurological exam, burn surface area and depth, associated injuries, past medical history, medications, allergies, tetanus status, and events surrounding the injury.
Rule of Nines
The rule of nines is a technique to quickly estimate total body surface area (TBSA) burned in adults. The body is divided into sections that represent 9% or multiples of 9% of the total body area:
- Head and neck: 9%
- Anterior trunk: 18%
- Posterior trunk: 18%
- Right arm: 9%
- Left arm: 9%
- Right leg: 18%
- Left leg: 18%
- Genitals: 1%
The provider estimates the burn area in each section as a percentage. These percentages are added together to determine total TBSA burned.
Lund-Browder Chart
The Lund-Browder chart adjusts the rule of nines for variations in body proportion by age. It is used to calculate TBSA burned for infants and children.
Parkland Formula
The Parkland formula uses the TBSA burned to guide fluid resuscitation needs:
- 4 ml x %TBSA burned x kg body weight = total fluid needed for the first 24 hours
- Give half the fluid in the first 8 hours from the time of burn
- Give the second half over the following 16 hours
It provides an initial target for fluid administration, which is then titrated based on clinical assessments of perfusion and urine output.
Baux Score
The Baux score helps predict mortality in burn patients. It is calculated by adding the age of the patient plus the %TBSA burned. A score greater than 100 indicates high mortality risk.
Priorities in Burn Care Based on Assessment
The primary assessment of airway, breathing, circulation, and disability/neurological status guides the management priorities and interventions for burn patients:
- Airway compromise – Early definitive airway control with intubation.
- Inadequate breathing – Oxygen, bronchodilators, intubation, and mechanical ventilation as needed.
- Circulatory insufficiency – Aggressive intravenous fluid resuscitation guided by formulas.
- Neurological deficits – Imaging studies to identify injuries, rehabilitation consults.
- Critical burn size – Transfer to a specialized burn center if TBSA burned is >10-20% in adults, >5-10% in children, or if circumferential limb or torso burns are present.
- Pain control – Analgesia with IV opiates or nerve blocks.
- Wound care – Cleaning, debriding, topical agents, dressings.
- Infection prevention – Tetanus prophylaxis, antibiotics if indicated.
- Nutritional support – Early feeding with high protein oral or enteral supplementation.
Conclusion
Thorough assessment and prompt intervention saves lives in burn injuries. Airway, breathing, circulation, and disability are evaluated first to identify any immediate threats. Burn size, depth, location, and associated injuries provide key information for ongoing management. Formulas guide fluid administration and prognostic estimates. Regular re-evaluation is essential to detect any changes in the patient’s condition over time. An organized ABC approach, coupled with accurate diagnostic assessments and appropriate prioritization of interventions, gives burn victims the greatest chance for survival with the best possible outcomes.
