• Burns >15% total body surface area (TBSA) in Adults and >10% in children can cause profound circulatory shock that can occur from both large fluid losses through tissue damage and from a systemic inflammatory response10.
  • Haemodynamic instability is rarely due to the burn alone and should prompt us to look for other causes
  • Circumferential limb burns can compromise blood supply distally


  • A thorough assessment of the extent of a burn is paramount: Burns <15% in adults and <10% in children do not require immediate fluid resusitation9
  • Capillary refill time (CRT), blood pressure and mucous membrane assessment are important indicators of hydration status but may be hard to measure due to location of the burn10.
  • Though rarely immediately helpful in the Emergency Department setting, early catheterisation is important as urine output is a reliable sign that can demonstrate poor perfusion and serve as a guide to ongoing resuscitation9, 10, 13.
  • In a significant burn there can be an increased metabolic demand on the patient which can cause organ dysfunction. Therefore, important baseline tests to consider are full blood count, urea and electrolytes, coagulation profile, liver function tests, amylase, C-reactive protein and capillary blood glucose. This also helps to identify any other issues impacting on the patient. If the patient is likely to go to theatre a serum group and save is warranted.
  • In circumferential limb burns, blood supply to the extremities should be checked regularly. If unable to do this clinically, a Doppler ultrasound can be used9,10, 11, 13.


  1. Immediate intravenous (IV) access and, if required, fluid resuscitation are critical steps in initial care9, 10, 11, 13.
  2. Blood tests
  3. Evaluate any areas of circumferential burns in limbs and constantly reassess perfusion

Any deterioration in the circulation to a limb could indicate ischaemia or a compartment syndrome. This warrants immediate discussion with a burns centre and may require urgent intervention such as escharotomy or fasciotomy9,10.

Top tips:

  • IV access is paramount. If it is not possible to get IV or IO access through unburnt skin, access is mandated through burnt tissue.
  • Creatine kinase is a useful test to perform to assess muscle breakdown9.