Circulation

After assessment of the airway and breathing, the circulation is the next most urgent consideration in the major burn patient.

Direct pressure should be applied to any actively bleeding sites. A brief cardiovascular examination should assess for signs of hypovolaemia:

• nail bed capillary refill time
• check the pulse:
  • centrally for tachycardia
  • peripherally for loss; this is vital in all cases of circumferential burns potentially necessitating escharotomy
• blood pressure

A significant burn may distract the examiner from serious internal injury with major blood loss.

In the adult, at least two large bore intravenous cannulae should be inserted through unburned skin. It is possible to put cannulae through burned skin but this is not desirable - they are more difficult to site and increase the risk of infection. Possible sites of access in order of preference are: forearm or antecubital fossa; external jugular or femoral vein; long saphenous vein at the ankle - but liable to occlude early. If there is no success, consider a 'cut down' at the antecubital fossa or ankle. Intraosseous circulatory access is an alternative in the burn patient less than two years of age.

Once access is obtained, blood is immediately sent for a range of investigations and fluid resuscitation is commenced - see main menu. A more detailed critique of the assessment of the circulation in trauma is given in the submenu.