Shahriar Shahrokhi

1.1Initial Assessment and Emergency Treatment

The initial assessment and management of a burn patient begins with prehospital care. There is a great need for efficient and accurate assessment, transportation, and emergency care for these patients in order to improve their overall outcome. Once the initial evaluation has been completed, the transportation to the appropriate care facility is of outmost importance. At this juncture, it is imperative that the patient is transported to facility with the capacity to provide care for the thermally injured patient; however, at times patients would need to be transported to the nearest care facility for stabilization (i.e., airway control, establishment of IV access).

Once in the emergency room, the assessment as with any trauma patient is composed of primary and secondary surveys (Box 1.1). As part of the primary survey, the establishment of a secure airway is paramount. An expert in airway management should accomplish this as these patients can rapidly deteriorate from airway edema.

Box 1.1. Primary and Secondary Survey

Primary survey:

•Airway:

–Preferably #8 ETT placed orally

–Always be prepared for possible surgical airway

•Breathing:

–Ensure proper placement of ETT by auscultation/x-ray

–Bronchoscopic assessment for inhalation injury

S.Shahrokhi, M.D., FRCSC

Division of Plastic and Reconstructive Surgery,

Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite D716, Toronto, ON M4N 3M5, Canada e-mail: shar.shahrokhi@sunnybrook.ca

•Circulation:

–Establish adequate IV access (large bore IV placed peripherally in nonburnt tissue if possible, central access would be required but can wait)

–Begin resuscitation based on the Parkland formula

Secondary survey:

•Complete head to toe assessment of patient

•Obtain information about the patient’s past medical history, mediations, allergies, tetanus status

•Determine the circumstances/mechanism of injury

–Entrapment in closed space

–Loss of consciousness

–Time since injury

–Flame, scald, grease, chemical, electrical

•Examination should include a thorough neurological assessment

•All extremities should be examined to determine possible neurovascular compromise (i.e., possible compartment syndrome) and need for escharotomies

•Burn size and depth should be determined at the end of the survey

Table 1.1 ABA criteria for transfer to a burn unita

1.Partial-thickness burns greater than 10 % total body surface area (TBSA)

2.Burns that involve the face, hands, feet, genitalia, perineum, or major joints

3.Third-degree burns in any age group

4.Electrical burns, including lightning injury

5.Chemical burns

6.Inhalation injury

7.Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality

8.Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols

9.Burned children in hospitals without qualified personnel or equipment for the care of children

10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention

aFrom Ref. [1]

Once this initial assessment is complete, the disposition of the patient will be determined by the ABA criteria for burn unit referral [1] (Table 1.1).

In determining the %TBSA (% total body surface area) burn, the rule of 9 s can be used; however, it is not as accurate as the Lund and Browder chart (Fig. 1.1) which further subdivides the body for a more accurate calculation. First-degree burns are not included.

Assessment of burn depth can be precarious even for experts in the field. There are some basics principles, which can help in evaluating the burn depth (Table 1.2). Always be aware that burns are dynamic and burn depth can progress or convert to being deeper. Therefore, reassessment is important in establishing burn depth.

Given that even burn experts are only 64–76 % [2] accurate in determining burn depth, there has been an increased desire to have more objective method of determining burn depth, and therefore, technologies have been and continue to be developed and utilized in this field. These are summarized in the following Table 1.3 [3]:

Once the initial assessment and stabilization are complete, the physician needs to determine the patient’s disposition. Those that can be treated as outpatient (do not