Following this initial assessment of the patient, the secondary survey should be completed. Associated injuries are not uncommon following a significant burn injury. Falls may occur in the attempt to leave a burning structure. Elderly patients may have an acute coronary syndrome secondary to the stress/hypoxia associated with the injury. Preexisting chronic illnesses must be identified. Impaired cognition is an important contributor to burn injury and a significant percentage of severely burned patients have a history of mental illness, dementia, or substance abuse. Preexisting cardiac, respiratory, or renal disease will have an impact on the success of resuscitation of the critically ill burned patient.
Age, along with burn size and the presence of inhalation injury, is one of the determinants of burn survival. The elderly have thinner skin that results in deeper burns requiring grafting and have limited reserve to survive the initial injury plus the multiple complicated procedures required for burn reconstruction. Early discussions with the patient and family will facilitate the clinical decisions that have to be made concerning future treatment plans.
Finally, the adjuncts to the primary and secondary survey have to be performed. A Foley catheter is necessary to monitor urinary output during the resuscitation. Gastric ileus often accompanies large burn injury and a nasogastric tube may be required. A gastric tube should certainly be placed in burns larger than 20 percent TBSA prior to transport to a tertiary burn center to reduce the incidence of emesis with aspiration.
Urinary output is the most reliable guide to the adequacy of resuscitation. In the adult, the goal is 0.5 mL/hr; in children less than 30 kg, the goal is 1 mL/hr. Again, it must be emphasized that urinary outputs significantly greater than these recommendations reflect excess fluid administration that will negatively affect respiratory function. Urinary output may initially be unreliable in patients with alcohol intoxication or chronic diuretic use.