3.1 Initial Assessment, Primary Survey (ABCDEF), and Field Stabilization

Initial Assessment, Primary Survey (ABCDEF), and Field Stabilization

Quick Summary: In the prehospital and emergency setting, burn care begins with ensuring rescuer safety, halting the burning process without precipitating hypothermia, and executing a systematic ABCDEF primary survey. Life-threatening physiological derangements take absolute precedence over burn wound care. Clinicians must maintain a high index of suspicion for early airway compromise, recognize thoracic restriction from circumferential eschar, initiate warming measures immediately, and obtain rapid vascular access for burns involving ≥20% Total Body Surface Area (TBSA).

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1. Scene Safety & Stopping the Burning Process

The initial phase of burn management occurs at the point of injury. Before initiating patient assessment, emergency responders and clinicians must ensure the environment is secure. Failure to establish scene safety places healthcare providers at severe risk and compromises patient outcomes.

                                STOPPING THE BURNING PROCESS
  ┌─────────────────────────────────┬─────────────────────────────────┬─────────────────────────────────┐
  │         THERMAL BURNS           │         CHEMICAL BURNS          │        ELECTRICAL BURNS         │
  ├─────────────────────────────────┼─────────────────────────────────┼─────────────────────────────────┤
  │ • Extinguish flames (Stop/Drop) │ • Don appropriate HazMat/PPE    │ • Secure and de-energize power  │
  │ • Cool with water <5-10 minutes │ • Brush off dry chemical powders│   source before touching victim │
  │ • NEVER use ice or ice-water    │ • Continuous copious water flush│ • Assume cervical spine trauma  │
  │ • Remove non-adherent clothing  │   for ≥20-30 minutes            │ • Continuous ECG monitoring for │
  │ • Remove all jewelry/rings early│ • Remove contaminated clothing  │   lethal dysrhythmias           │
  └─────────────────────────────────┴─────────────────────────────────┴─────────────────────────────────┘

Thermal Burns (Flame, Scald, Contact)

• Extinguish & Smother: Smother active flames using blankets, water, or the "Stop, Drop, and Roll" technique. Remove the patient from the heat source and smoky environment.
• Cooling Duration & Temperature: Cool the burn wounds immediately with clean, room-temperature tap water or normal saline for less than 5 to 10 minutes. Brief cooling dissipates residual dermal heat, decreases histamine and kinin release, and limits burn depth progression.
• The Ice Prohibition: Never apply ice, ice water, or freezing compresses. Ice causes profound cutaneous microvascular vasoconstriction, ischemia, and cellular crystallization. It accelerates tissue necrosis in Jackson's zone of stasis and rapidly induces severe systemic hypothermia.
• Clothing & Jewelry Removal: Immediately remove smoldering, hot, or wet clothing. Synthetics (e.g., polyester, nylon) that have melted into the skin should be cut around; never forcefully rip adherent fabric from the wound bed. Remove all jewelry, rings, watches, belts, and body piercings immediately. As progressive post-burn interstitial edema evolves over the initial 24 to 48 hours, constrictive items act as severe tourniquets, precipitating acute distal digital and limb ischemia.

Chemical Burns

• Rescuer Protection (PPE): First responders must don chemical-resistant gloves, eye protection, and gowns prior to patient contact to avoid secondary chemical contamination.
• Dry Chemical Powders: Dry substances (e.g., dry lime, sodium hydroxide powder, dry lye) must be thoroughly brushed off the skin dry before any liquid irrigation. Adding water to dry lime produces an intense exothermic reaction that causes catastrophic combined chemical and thermal burns (calcium hydroxide production).
• Copious Water Lavage: Liquid chemicals require immediate, continuous, low-pressure, high-volume water lavage for at least 20 to 30 minutes (or until medical facility arrival and pH normalization). Neutralizing agents should never be applied, as chemical neutralization reactions generate extreme exothermic heat.
• Ocular Chemical Exposure: Continuous eye irrigation using a Morgan lens or continuous saline flush must be initiated immediately and continued until ocular pH reaches neutral (7.0–7.4).

Electrical Burns

• De-energize the Source: Rescuers must never touch an electrical burn victim until the power supply has been confirmed shut off, locked out, and grounded by authorized utility personnel.
• Concomitant Trauma & C-Spine: Electrical current induces violent tetanic muscle contractions and throws victims away from the contact point. Responders must immediately immobilize the cervical spine and assume occult musculoskeletal fractures, blunt organ injury, or spinal cord trauma.
• Continuous Cardiac Monitoring: High-voltage (≥1,000 V) and low-voltage (<1,000 V) AC/DC current disrupts myocardial transmembrane potential, predisposing patients to ventricular fibrillation, asystole, and severe conduction blocks. Immediate 12-lead ECG and continuous telemetry are mandatory.

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2. Advanced Primary Survey with Burn Extensions (ABCDEF)

The primary survey in burn trauma adapts the standard Advanced Trauma Life Support (ATLS) and Advanced Burn Life Support (ABLS) protocols into an expanded ABCDEF framework. Life-threatening conditions must be identified and managed simultaneously before moving to secondary assessments.

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3. Detailed Component Breakdown of the ABCDEF Primary Survey

A — Airway Maintenance with Cervical Spine Protection

Upper airway thermal injury occurs primarily above the vocal cords (supraglottic space) because the pharynx efficiently cools inhaled gases. However, thermal damage triggers rapid, massive submucosal edema that peaks between 12 and 24 hours post-injury. The primary clinical objective is proactive, early airway control before anatomical distortion makes intubation impossible.

                          SIGNS OF IMPENDING AIRWAY COMPROMISE
  ┌─────────────────────────────────────────────────────────────────────────────┐
  │ • Stridor, brassy cough, or progressive hoarseness                          │
  │ • Carbonaceous (soot-laden) sputum and oropharyngeal blistering             │
  │ • Singed nasal hairs, facial burns, and perioral full-thickness burns       │
  │ • Suprasternal, intercostal, or substernal retractions with air hunger      │
  │ • History of trapped closed-space fire exposure or explosion                │
  │ • Deep neck burns with circumferential constrictive eschar                  │
  └─────────────────────────────────────────────────────────────────────────────┘

[!WARNING] Waiting for arterial blood gas deterioration, declining oxygen saturation, or audible stridor before securing the airway is a critical error. Stridor represents a late sign indicating >85% laryngeal lumen occlusion. If airway edema progresses, endotracheal intubation becomes exceedingly difficult, necessitating an emergency surgical cricothyroidotomy.

• Intubation Standards: Use a large-diameter endotracheal tube (minimum 7.5 to 8.0 mm ID in adults) when possible. This accommodates subsequent diagnostic and therapeutic bronchoscopy for clearing sloughed mucosal casts and thick particulate debris.
• Tube Securing: Secure the endotracheal tube with cotton twill ties or commercial harness devices looped around the occiput. Standard adhesive tape does not adhere to burned facial skin and fails as facial edema expands.

B — Breathing and Ventilation

Inhalation of toxic combustion byproducts (carbon monoxide, hydrogen cyanide, aldehydes) causes acute tracheobronchial inflammation, loss of ciliary clearance, bronchospasm, and ventilation-perfusion mismatch.

• High-Flow Oxygen: Administer 100% humidified oxygen via a tight-fitting non-rebreather mask (NRB) immediately to all patients with suspected smoke inhalation or significant burns. Inhaling 100% O2 reduces the elimination half-life of carboxyhemoglobin ($COHb$) from 320 minutes on room air down to approximately 40 to 60 minutes.
• Pulse Oximetry Limitation: Standard pulse oximeters ($SpO_2$) cannot differentiate between oxyhemoglobin and carboxyhemoglobin ($COHb$) because both absorb light at 660 nm. A patient with severe, life-threatening carbon monoxide poisoning ($COHb > 40%$) will falsely display a normal or near-normal $SpO_2$ reading (e.g., 99–100%). Arterial blood gas analysis with co-oximetry is mandatory to measure true carboxyhemoglobin levels.
• Circumferential Torso Burns & Thoracic Restriction: Full-thickness, leathery circumferential burns across the anterior chest and abdominal wall lose elasticity. As fluid resuscitation progresses, severe sub-eschar edema generates a rigid, unyielding cage. This leads to:
  1. Precipitous drops in dynamic pulmonary compliance.
  2. Spiking peak inspiratory airway pressures ($>40\text{ cm }H_2O$ on mechanical ventilation).
  3. Hypoventilation, respiratory acidosis, and progressive hypoxia.
  4. Increased intrathoracic pressure that compresses the vena cava, reducing venous return and precipitating obstructive/hypovolemic shock.
• Intervention: Emergent chest escharotomy is required to release the constricting band along the anterior axillary lines and subcostal margins.

C — Circulation and Hemorrhage Control

Burn shock is a unique combination of distributive and hypovolemic shock resulting from massive systemic capillary hyperpermeability, fluid extravasation into the interstitium, and loss of intravascular plasma volume.

• Vascular Access:
  • Establish two large-bore peripheral intravenous lines (16-gauge or 18-gauge) immediately in adults.
  • Cannulation through non-burned skin is preferred; however, burned skin can and must be used without delay if unburned sites are unavailable. Peripheral lines placed through burned tissue should be secured with suture or gauze wrap.
  • If peripheral IV access cannot be established within minutes, establish intraosseous (IO) access (proximal tibia or humeral head) or ultrasound-guided central venous access.
• Peripheral Pulse Monitoring in Extremity Burns: Circumferential full-thickness extremity burns place the limb at high risk for extremity compartment syndrome. Clinicians must palpate or insonate distal arterial pulses (radial, ulnar, dorsalis pedis, posterior tibial) using a Doppler ultrasound flow detector every hour.

                          SIGNS OF LIMB ISCHEMIA / COMPARTMENT SYNDROME
  ┌─────────────────────────────────────────────────────────────────────────────┐
  │ • Loss or progressive attenuation of Doppler arterial pulse signals         │
  │ • Delayed capillary refill (>2-3 seconds) or cool, pale/cyanotic digits     │
  │ • Severe, unremitting pain out of proportion to exam, aggravated by passive │
  │   stretch of the distal muscle groups                                       │
  │ • Progressive motor weakness or paresthesia/numbness (deep tissue ischemia) │
  │ • Compartment tissue pressures >30 mmHg measured via needle manometer       │
  └─────────────────────────────────────────────────────────────────────────────┘

D — Disability and Neurological Assessment

Assess neurological status using the AVPU scale (Alert, Voice, Pain, Unresponsive) and calculate the Glasgow Coma Scale (GCS) score. Evaluate pupillary symmetry, size, and light reactivity.

[!NOTE] Thermal burn injury alone does not cause immediate coma or altered mental status. If a burn patient presents with confusion, lethargy, agitation, or unresponsiveness, the nurse must aggressively investigate secondary etiologies:

1. Severe systemic hypoxia or upper airway occlusion.
2. Acute Carbon Monoxide (CO) poisoning ($COHb$ toxicity).
3. Acute Hydrogen Cyanide ($HCN$) toxicity (metabolic acidosis with severe lactic acidemia).
4. Concomitant closed head injury / traumatic brain injury (TBI) from explosions or falls.
5. Hypoglycemia (always obtain immediate point-of-care capillary blood glucose).
6. Acute alcohol or drug intoxication.

E — Exposure and Environmental Control (Hypothermia Prevention)

Patients with extensive thermal burns have lost the protective stratum corneum barrier, disrupting normal evaporative regulation. Damaged dermal capillary beds cannot vasoconstrict, resulting in massive radiant and convective heat loss.

• The Lethal Triad: Hypothermia ($<35^\circ\text{C} / 95^\circ\text{F}$) combined with metabolic acidosis and coagulopathy constitutes the "lethal triad" in trauma and burn care. Hypothermia impairs platelet aggregation, inhibits clotting factor enzymatic cascades, induces cardiac dysrhythmias (including refractory ventricular fibrillation), and increases mortality threefold.
• Environmental Warming Protocol:
  • Completely strip all wet, burned, or contaminated clothing.
  • Cover the patient immediately with clean, dry linens, thermal blankets, and radiant warmers.
  • Maintain ambient emergency department and transport vehicle temperatures above 85°F to 90°F (28°C to 32°C).
  • Warm all infused intravenous fluids and blood products using in-line fluid warmers (target 37°C–40°C).
  • Never apply wet dressings, wet towels, or water-soaked blankets during inter-facility transport.

F — Fluid Resuscitation Initiation

For patients with second- and third-degree burns involving ≥20% TBSA (or ≥10% to 15% in pediatric or elderly populations), initiate crystalloid resuscitation using Lactated Ringer's (LR). Prehospital or emergency consensus starting rates should be initiated promptly based on patient weight and estimated surface area while awaiting formal calculations.

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4. Secondary Survey & AMPLE History

Once the primary survey is complete and immediate life threats are controlled, proceed to the secondary survey. This consists of a complete, systematic head-to-toe physical examination and gathering a focused medical history using the AMPLE mnemonic.

                                THE AMPLE HISTORY IN BURN CARE
  ┌───┬──────────────────────────┬─────────────────────────────────────────────────────────────┐
  │ A │ Allergies                │ Medications, topical agents, antibiotics, latex, analgesics │
  ├───┼──────────────────────────┼─────────────────────────────────────────────────────────────┤
  │ M │ Medications              │ Anticoagulants, beta-blockers, antihypertensives, insulin   │
  ├───┼──────────────────────────┼─────────────────────────────────────────────────────────────┤
  │ P │ Past Medical History /   │ Cardiac/renal disease, diabetes, COPD, psychiatric history, │
  │   │ Pregnancy                │ current pregnancy status (fetal viability and monitoring)   │
  ├───┼──────────────────────────┼─────────────────────────────────────────────────────────────┤
  │ L │ Last Meal / Liquid Intake│ Time of last oral intake (aspiration risk during airway     │
  │   │                          │ manipulation or emergent surgery)                           │
  ├───┼──────────────────────────┼─────────────────────────────────────────────────────────────┤
  │ E │ Events & Environment     │ Exact mechanism, enclosed vs open space, explosion/blast,   │
  │   │ Surrounding Injury       │ duration of exposure, chemical agents, toxic fumes inhaled  │
  └───┴──────────────────────────┴─────────────────────────────────────────────────────────────┘

Systematic Secondary Head-to-Toe Inspection

• Head, Eyes, and Face: Inspect periorbital tissues. Perform fluorescein staining and wood lamp exam if facial/flash burns are present to evaluate for corneal burns or abrasions.
• Ears & Oropharynx: Check auditory canals; evaluate tympanic membranes for rupture, which frequently occurs in blast and explosion injuries. Inspect posterior pharynx for soot or erythema.
• Torso & Posterior Back: Logroll the patient with spinal motion precautions to inspect the entire back, gluteal folds, and posterior thighs. Failing to logroll leads to missed burns and significant underestimation of TBSA.
• Perineum & Genitalia: Inspect for scrotal, labial, or perineal involvement. Deep perineal burns require early urinary catheter placement before progressive swelling obliterates the urethral meatus.
• Extremities & Musculoskeletal: Palpate for long-bone fractures, joint dislocations, deep soft tissue crush injuries, and monitor distal pulses continuously.