General Assessment of a Patient with Burns

Original Editor - Carin Hunter based on the course by [TUTOR LINK/ ReLab]
Top Contributors - Jess Bell, Carin Hunter, Tarina van der Stockt, Rucha Gadgil, Ahmed M Diab and Kim Jackson

Burn Assessment

When treating a patient with a burn, the first step is an accurate assessment. The time spent on an assessment will not only optimise their immediate treatment and minimise any long term injury they might be vulnerable to, but it will also help the patient to achieve their highest functional level. A complete assessment also will increase the chance of patient compliance as it offers the multidisciplinary team the opportunity to remind themselves of the patients long term goals and align their therapy to these objectives. A burn injury in unique to every situation and patient, and a clear assessment will help the team to be united in their efforts. The multidiciplinary team should be aware of the importance of an early and adequate assessment of  the burn patients for optimal functional and cosmetic outcomes to minimise the impact of the  trauma long term. For continuity it is helpful for the Initial Assessment to be available to all further disciplines conducting their assessments, and all these assessments be forwarded onto the rehabilitation setting and ideally, into the community setting. This continuity of information will lessen the frustration of the patient having to re-explain the story and it insures the information transferred is as accurate as possible.

Flow chart illustrating the assessment and management of the burn

Short Term Goals:

1. Prevent respiratory complications
2. Control Oedema
3. Maintain Joint ROM
4. Maintain Strength
5. Prevent Excessive Scarring

Risk Factors:

1. Injury Factors:
   1. Inhalation injury
   2. Burn area - systemic inflammatory reaction syndrome involving the lungs
   3. Depth of burn
   4. Scarring
2. Patient Factors
   1. Reduced ambulation and mobility
   2. Increased bed rest
   3. Increased pain
   4. Pre-existing co-morbidities
3. Treatment Factors
   1. Skin reconstruction surgery
   2. Invasive monitoring and procedures
   3. Management in critical care

Subjective Assessment

The following pieces of information should be included in the Subjective Assessment:

1. Inhalation injury
2. Total Body Surface Area (TBSA)
3. Burn Type and Depth
4. Burn Site and Impact
5. Present History
6. Any surgical or medical management
7. Past History (Including Medical/ Drug)
8. Social History

1. Inhalation Injury

During the subjective assessment, if the patient was in an enclosed space or is presenting with a reduced level of consciousness, it is imperative to make a note to conduct, or speak to the team member who can conduct, an Inhalation Injury Examination which will allow treatment to commence as soon as possible. When conducting a Subjective Assessment, the clinician should note any physical signs of inhalation injury such as charring around the mouth and nostrils.

(2 - ANZBA 2007; British Burn Association 2005; 1 - Eisenmann-Klein 2010)

2. Total Body Surface Area

There are many methods on conducting a Total Body Surface Area (TBSA) assessment. The most accurate method is the Rules of Nines and Lund and Brower method. Another commonly used method is the Palmer Surface Method, whereby the patients palm size, (representing 1% TBSA) is used to estimate the total burns coverage. Please note, when assessing the burnt area, oedema should not be included.

When conducting the TBSA assessment, there are two main considerations:

1. The Parkland Formula for fluid resuscitation
2. When a patient has more than 20–25% TBSA a systemic inflammatory reaction is seen which is known to affect all body organs. This poses a risk for the respiratory system.

Please see Introduction to Burns for more information regarding TBSA Assessment

3. Burn Type and Depth

It is important to regularly re-examine the extent of tissue destruction as it can change up to 48 hours post burn. It is uncommon for a burn to present uniformly with a singe depth throughout. Quick administration of first aid can influence the type and depth to a large extent. ( British Burn Association 2005)

Click here for more information on Jacksons’ Burn Wound Model.  

4. Burn Site and Impact

The burn site can have a large impact of the potential functional outcome and the trauma associated with the injury. There are four High Impact areas associated with burns and this requires an awareness of the clinician assessing as these areas require specialised treatment.

High Impact Areas:

1. Hands
2. Face
3. Perineum
4. Joints

5. Current History

When conducting the current history questioning, please be aware of the emotional trauma that could be associated with a burn injury. If there is a family member or witness around, they can also be asked to fill in areas of the history that either the patient cannot recall, or that they are battling emotionally to elaborate on.

Important aspects to cover:

• History of the incident
  • Specific attention paid to the mechanism of injury
• First aid
  • An accurate account of what treatment was given?
  • On site medication administered needs to be explained clearly with amounts and times given as this could react with the medication administered on admission to hospital
  • If no adequate first aid was administered, suspect deeper burn injury
• Falls
  • Is there any indication that the patient fell?
  • What height did they fall from?
  • Suspect a possible head  injury, sprain or fracture
• Electrical injury
  • What voltage was involved?
  • Which parts of the body was in contact with earth?
  • Suspect nerve or deep muscle injury with high voltage current  
• Explosions
  • Suspect a fall, high velocity injury or possible tympanic membrane injury, as the latter would cause a loss of  hearing and difficulty communicating
• Passage to hospital and time to admission

ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010

6. Medical and Surgical History

• Pain medication
• Debridement
• Escharectomy
• Flaps/grafts
• Any particular MDT instructions to be followed

ANZBA 2007; British Burn Association 2005; Hettiaratchy et al 2004

7. Past History

• Include any medical history
• Previous surgical interventions
• Medication
  • Amount
  • Duration on medication
  • Condition controlled or uncontrolled

8. Social History

ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010

• Basic activities of daily living. These vary from person to person, some examples:
  • Dressing
  • Bathing
  • Eating
  • Shopping
  • Driving
  • Home maintenance
• Past physical function
  • General mobility
  • Stair mobility
  • Lifting
• Past physical fitness
  • Strength
  • Flexibility
  • Endurance
  • Balance
• Social support and home situation
• Occupation
  • Particularly important for hand burns

Psychosocial Factors/ Yellow Flags

• Self-image
• Coping style
• Mental health
• Emotional behaviour  

ANZBA 2007; British Burn Association 2005; Hettiaratchy et al 2004

Objective Assessment

Pain Intensity Assessment

Visual Analogue Scale

Observational behavioural pain assessment scales should be used to Measure pain in children aged 0 to 4 years e.g.

• Visual Analogue Scale (VAS) and the Wong-Baker FACES pain rating scale
  • Visual analogue scale can have the faces used alongside but also has numbers assigned below the faces which the patient uses to indicate their pain scores.
  • VAS can be used from age 12 upwards and is suitable for adults.
  • Wong-Baker FACES consists of 6 pain assessment cards that vary from a smile to sad to crying facial expressions representing pain behavior rating and is supervised by the Chinese Association for the Study of Pain (CASP). The patient chooses the best card to represent the pain intensity.
  • Faces pain rating scale can be used in children aged 5 years and older.
• The FLACC scale
  • 5 categories:
    • Face
    • Legs
    • Activity
    • Cry
    • Consolability
  • each of which accounts for scores of 0 to 2. With 10 as the full mark, 0 to 3, 4 to 7 and 8 to 10 scores represent no/light pain, moderate pain and acute pain, respectively

• COMFORT scale
  • 6 categories including
    • Alertness
    • Calmness/agitation
    • Crying
    • Physical movement
    • Muscle tone
    • Facial tension
  • With a full mark of 30, each category is scored on a 1 to 5 scale. In practice, suggestive information is offered according to the sum of the scores among the 6 categories. The higher scores one obtains, the more violent the pain (Table S1). Necessary pain interventional therapies shall be taken if the scores add up to more than 17
• Pain Observation Scale for Young Children (POCIS)
  • used for pain behavioral assessment with points ranging from 0 to 7, in which 0, 1 to 2, 3 to 4 and 5 to 7 are recorded as no pain, slight pain, moderate pain and severe pain, respectively, with 7 categories each contributing 0 or 1 point towards the overall score

For more information regarding Pain Assessment Tools please see:

• British Pain Society Outcome Measures
• Physiopedia page on Outcome Measures
• Zieliński J, Morawska-Kochman M, Zatoński T. Pain assessment and management in children in the postoperative period: A review of the most commonly used postoperative pain assessment tools, new diagnostic methods and the latest guidelines for postoperative pain therapy in children. Adv Clin Exp Med. 2020 Mar 1;29(3):365-74.

Burn Outcome Measures

When treating patients in a multidicsciplinary team, it is useful to use outcome measures that can be retested as the condition progresses. Some examples:

1. Burn Specific Health Scale -Brief (BSHS-B): Examine the  physical and psychosocial functioning of burn patients and their quality of life. McMahon 2008;Brusselaers et al 2010; Wasiak et al 2011
2. Burns Scar Index (Vancouver Scar Scale)
3. Burns Specific Pain Anxiety Scale

Taal LA, Faber AW, Van Loey NE, Reynders CL, Hofland HW. The abbreviated burn specific pain anxiety scale: a multicenter study. Burns. 1999 Sep 1;25(6):493-7. - file:///C:/Users/mamad/Downloads/taal1999BSPAS.pdf

https://www.sciencedirect.com/science/article/abs/pii/S0305417996001179

Taal LA, Faber AW. The burn specific pain anxiety scale: introduction of a reliable and valid measure. Burns. 1997 Mar 1;23(2):147-50.

Inhalation Assessment

Physical signs are not the most reliable and accurate tools for assessment but they can contribute to the whole assessment of the patient. Physical signs should be included with clinical tests, regular re-assessment and correct initial management.

Initial management:

• Quick transportation to the emergency room
• Conscious
• Patent airway
• Chest radiograph
• Arterial blood gases

Physical Signs (ANZBA 2007; British Burn Association 2005)

• Soot stained sputum
• Stridor (Noisy breathing due to an obstructed airway)
• Wheezing
• Facial burns
• Singed nasal hairs
• Anxiety
• Cough
• Stupor
• Dyspnea
• Hoarse vocal quality  
• Singed facial / nasal hair  
• Oedema
• Erythema (Superficial reddening of the skin, usually in patches, as a result of injury  or irritation causing dilatation of the blood capillaries)
• Inspiratory and end expiratory crackles on auscultation  
• Chest x-ray changes
• Signs of Hypoxia
  • Headache
  • Shortness of breath
  • Fast heartbeat
  • Coughing
  • Wheezing
  • Confusion
  • Bluish color in skin, fingernails, and lips

Bronchoscopy Assessment:

• Bronchoscopy assists with rapid diagnosis of inhalation injury and grading it be unavailable to the clinician and is considered the gold standard
• Inhalation Injury signs on bronchoscopy:
  • Erythema
  • Edema (which may be seen as a blunting of the carina)
  • Mucosal blisters
  • Erosions
  • Hemorrhages
  • Bronchial secretions
  • Soot deposits
• Indirect laryngoscopy permits visual assessment to the level of the vocal cords and can be a useful, albeit limited, tool should

Three determinants of injury severity

• Duration of smoke exposure
• Temperature of the inhaled smoke
• Composition of the smoke

For the latest recommendations please see:

• A Critical Update of the Assessment and Acute Management of Patients with Severe Burns
• Inhalation Injury in the Burned Patient

Oedema Assessment

WORDS CARIN!!!!!!

Stage of Oedema	Appearance of Oedema
Stage 1	Soft, may pit on pressure
Stage 2	Firm, rubbery, non-pitting
Stage 3	Hard, fibrosed

Clinical stages and appearance of oedema

When assessing oedema, the subjective component includes when the swelling began and any changes in the oedema with position. The objective assessment needs to be carefully carried out so there is a reduced risk on infection and no increase in pain.

The most commonly used tools to measure edema are:

1. Volume measurements (with a water volumeter)
2. Girth measurements (with a tape measure).
3. Pitting edema assessment (based on the depth and duration of the indentation).

For more information on how to conduct these measurements, please see Oedema Assessment

Physical Assessment

When conducting a physical assessment, it is often helpful to break up the assessment into two section. Firstly the upper limbs, lower limbs and trunk, secondly, general functional mobility. When conducting a physical assessment, it is important to consider complicating factors such as prolonged bed rest, high levels of pain and pre-existing co morbidities.

(ANZBA 2007; Hettiaratchy et al 2004; Settle 1986; Siemionow and Eisenmann Klein 2010)

• Limbs and Trunk
  • Assessment of:
    • Joint range of motion
    • Muscle Strength
    • Muscle Length
  • Limiting factors:
    • Pain
    • Muscle length
    • Trans-articular burns
    • Scar contracture
    • Individual  specificity of the burn
• General Functional Mobility
  • The mobility assessment should only be carried out once the patient is medically stable and the focus is:
    1. Prevention of complications associated with prolonged bed rest
    2. Restoration of function & independence.
  • Factors to be assessed:
    • Functional transfers
    • Gait
    • Endurance
    • Balance
  • Factors to consider:  
    • Posture
    • Activities of daily living
    • Demands of vocational roles
    • Cardiovascular response to mobilisation  
    • Neurological status
    • Pain
    • Concomitant injuries/weight-bearing status