General Assessment of a Patient with Burns

Original Editor - Carin Hunter
Top Contributors - Jess Bell, Carin Hunter, Tarina van der Stockt, Kim Jackson, Rucha Gadgil and Ahmed M Diab

Burn Assessment

Each individual with a burn injury is unique. Management should always be tailored to the individual and their specific context. This requires a detailed and accurate initial assessment. Investing time in the initial evaluation helps ensure the best possible immediate care, reduces the risk of long-term complications, and maximises a patient's functional recovery. By conducting a comprehensive assessment, the multidisciplinary team can become familiar with the patient's long-term goals and align therapy to these objectives. This, in turn, enhances patient engagement with the treatment plan.

Sharing initial assessment findings with relevant members of the multidiciplinary team helps to streamline subsequent assessments and facilitates continuity of care, both during rehabilitation and upon transition to community settings. This approach helps to minimises patient frustration and ensures accurate transmission of relevant information throughout the treatment journey.

Goal Setting

The multidisciplinary team should assess a patient and set goals using the SMART goal method with each patient. SMART goals are specific, measurable, attainable, realistic and time-bound.

Short-term rehabilitation goals might include:

• preventing respiratory complications
• controlling oedema
• maintaing joint range of motion
• maintaing strength
• preventing excessive scarring

Risk factors to consider:

• injury factors:
  • inhalation injury
  • burn area - systemic inflammatory reaction syndrome involving the lungs
  • depth of burn
  • scarring
• patient factors
  • reduced ambulation and mobility
  • increased bed rest
  • increased pain
  • pre-existing co-morbidities
• treatment factors
  • skin reconstruction surgery
  • invasive monitoring and procedures
  • management in critical care

Functional long-term goals might include:

1. achieving functional independence
2. improving participation in society
3. maintaining / enhancing psychological well-being
4. establishing / achieving a return to work plan

Key Aspects of the Initial Subjective Assessment of a Patient with a Burn Injury

The following sections discuss essential components to cover when determining the history and conducting a subjective evaluation of a patient with a burn injury.

1. Inhalation Injury

During the subjective assessment, clinicians should carefully observe for signs of inhalation injury, especially in cases where there is a history of exposure to fire and smoke within enclosed spaces, coupled with diminished levels of consciousness. Physical indicators may include charring around the mouth and nostrils, singed nasal hairs, presence of soot in sputum and upper airways, alterations in voice quality, and the presence of wheezing. If any signs of inhalation injury are noted, a qualified member of staff must conduct an inhalation injury examination. This ensures the prompt initiation of appropriate treatment measures.

2. Total Body Surface Area

Various methods are used to conduct a Total Body Surface Area (TBSA) assessment, including the Rules of Nines and Lund and Brower methods. The Lumd and Brower method is considered more accurate than the Rule of Nines. The Palmar Surface Method is also commonly used. This method estimates burn coverage based on the patient's palm size (where each palm represents approximately 1% TBSA). Please note, you should not include oedema when calculating burn size area.

Important TBSA considerations:

Predicting TBSA is important for fluid resuscitation. The Parkland Formula is still widely used to determine appropriate fluid resuscitation over the first 24 hours.

Parkland Formula = 4 mL/kg/%TBSA (3 mL/kg/%TBSA in children) = total amount of crystalloid fluid during first 24 hours

However, it is important to note that "no formula is comprehensive enough to include the true complexity of burns as there are many unaccounted clinical variables [...but] the Parkland formula is a reasonable starting point for achieving adequate fluid resuscitation despite its limitations."

When a patient's burn injury exceeds 20–25% TBSA, a systemic inflammatory reaction may occur, which impacts multiple organ system, including the respiratory system.

Please see Burn Wound Assessment for more information on the TBSA Assessment. Please see Systemic Response to Burns for more information on the whole body response to burn injuries.

3. Burn Type and Depth

It is important to regularly re-examine the extent of tissue destruction as it can change for at least 48 hours post burn. Burn injuries rarely present uniformly with a singe depth throughout the affected area. Early management interventions and other patient factors (e.g. age and health) can influence the type and depth of a burn.

4. Burn Site and Impact

The location of a burn injury can significantly impact functional outcomes and the level of trauma experienced by a patient. Burns to certain areas of the body require specialised treatment because of their functional importance and the risk for potential complications. These critical areas include:

• hands
• face
• perineum
• joints

5. History of Burn Injury

When conducting the subjective history, it is essential to consider emotional trauma that may be associated with a burn injury. Consider if it is appropriate to involve family members or witnesses to fill in gaps in the history or to provide additional context.

• History of the incident
  • pay close attention to the events leading up to the injury and the mechanism of injury
• First aid
  • document any first aid administered: if first aid was inadequate, clinicians should suspect a deeper burn injury
  • include details of medications administered on site, specifying amounts and times given: this helps to avoid adverse medication interactions
• Falls
  • is there any indication that the patient fell?
  • if yes, what height did they fall from?
  • when there is a history of falls, consider the potential for head injury, fractures, sprains, etc
• Electrical injury
  • in cases of electrical injuries, what voltage was involved and which parts of the body were in contact with earth?
  • in cases where there has been a high voltage current, suspect nerve or deep muscle injury
• Explosions
  • often associated with falls, high velocity injuries
  • can also be associated with tympanic membrane injury, which can cause hearing loss and affect communication
• Passage to hospital
  • document the mode of transportation and time to admission

6. Medical and Surgical History

Find out about any medical or surgical management:

• what pain medication has been given?
• what procedures so far? Debridement, escharotomy, flaps/grafts, etc
• what instructions are there from the multidisciplinary team?

7. Past History

Find out about:

• general medical history
• previous surgical interventions
• medication: including amount, duration and if conditions are controlled or uncontrolled by medication

8. Social History

In the social history, find out about a patient's pre-injury level of function, including:

• activities of daily living:
  • basic activities of daily living: these vary from person to person, but can include dressing, bathing, eating, shopping, driving, home maintenance
  • pre-injury physical function: mobility, including stair mobility, lifting ability
  • pre-injury physical fitness: strength, flexibility, endurance, balance
• social supports and home situation

• occupation: particularly relevant for patients with burns to their hands

Psychosocial Factors/ Yellow Flags

For individuals with burn injuries, it is important to consider:

• self-image
• coping style
• mental health
• emotional behaviour  

Key Aspects of the Objective Assessment of a Patient with a Burn Injury

The following sections discuss the key components of the objective assessment for a patient with a burn injury.

1. Pain Intensity Assessment

When assessing pain intensity in individuals with burn injuries, various observational behavioral pain assessment scales are utilised, depending on the patient's age:

• Visual Analogue Scale (VAS)
  • suitable for measuring pain in individuals aged 12 and older
  • patients are asked to mark their level of pain on a horizontal line, where one end represents no pain and the other end represents the worst pain imaginable
• Wong-Baker Faces Pain Scale
  • a self-report measure used to assess the intensity of a child's pain
  • consists of six pain assessment cards that show faces with different emotions, from a smile to crying (see Figure 1)
  • can be used in children aged 5 years and older
• Face, Legs, Activity, Cry, and Consolability (FLACC) scale
  • observational pain scale
  • widely used in the paediatric population to assess pain in infants and children who are unable to verbally express their pain
  • it scores pain intensity by rating five behaviours (face, legs, activity, cry, consolability) on a 0 to 2 scale:
    • 0 to 3 = no / light pain
    • 4 to 7 = moderate pain
    • 8 to 10 = acute pain

• COMFORT Behavior Scale (CBS)
  • used to assess pain and distress in intubated and self-ventilating children in paediatric intensive care units
  • includes six categories, which are scored on a 1 to 5 scale, with a maximum score of 30:
    • alertness
    • calmness/agitation
    • crying
    • physical movement
    • muscle tone
    • facial tension
  • higher scores = greater pain / distress
• Pain Observation Scale for Young Children (POCIS)
  • used to assess pain in children
  • focuses on observing specific behaviors that indicate pain in children, particularly those aged between 1 and 5 years old
  • typically has seven items, which represent observable behaviours associated with pain in young children (e.g. facial expressions, movement, crying, etc)
  • higher scores = greater pain

For more information on Pain Assessment Tools, please see:

• British Pain Society: Outcome Measures
• Physiopedia page: Outcome Measures

2. Burn Outcome Measures

When managing patients with burn injuries within a multidisciplinary team, it is beneficial to use outcome measures that can be retested as the condition progresses. Some examples of outcome measures include:

• Burn Specific Health Scale -Brief (BSHS-B): evaluates the physical and psychosocial functioning of burn patients and their quality of life
• Burns Scar Index (Vancouver Scar Scale): the first tool to be validated to assess burn scars and is still widely used; it focuses on four indicators (scar height and thickness, pliability, vascularity, and pigmentation)
• Burns Specific Pain Anxiety Scale: evaluates pain-related anxiety in patients with burn injuries

3. Inhalation Assessment

"No consensus exists regarding the diagnosis, grading, and prognosis of inhalation injury [...] Full manifestation occurs up to 48 hours after the inhalation insult once the inflammation reaches its peak. Further, the clinical presentation (degree of respiratory failure) may not correspond with the intensity of the exposure."

The majority of patients with inhalation injuries who present early to an emergency department will be conscious with patent airways. Their initial chest radiograph and arterial blood gases may "appear at most only slightly abnormal." Because of delayed presentations or non-specific presentations, a number of diagnostic adjuncts are used to diagnose inhalation burn injuries.

Physical findings: please note that physical findings, while valuable, can sometimes be misleading and must be considered alongisde other diagnostic tools. Key physical findings include:

• sooty sputum
• stridor (noisy breathing due to an obstructed airway)
• wheezing
• facial burns
• singed nasal/ facial hairs
• anxiety
• cough
• stupor
• dyspnoea
• hoarse voice   
• oedema
• erythema (superficial reddening of the skin, usually in patches)
• 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:

• fiberoptic (flexible) bronchoscopy (FOB) is the gold standard for diagnosis of an inhalation injury
• it provides an immediate view of the airway
• while not universally available, it is widely used
• signs of inhalation injury on bronchoscopy may include:
  • erythema
  • oedema (which may be seen as a blunting of the carina)
  • mucosal blisters
  • erosions
  • haemorrhages
  • bronchial secretions
  • deposits of soot
• indirect laryngoscopy can serve as an alternative when broncoscopy is unavailable, offering visualisation as far as the vocal cords

Key determinants of inhalation injury severity include:

• duration of exposure to smoke
• temperature of the inhaled smoke
• smoke composition

For more information on inhalation injuries, please see:

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

4. Oedema Assessment

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. It is good to know how to assess oedema by stage and by size.

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

Oedema Classification Table

The most commonly used tools to measure oedema 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

5. 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.

• 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
    • Concomitant injuries/weight-bearing status