Inhalational injury can also cause damage to the lower airway Chest radiographs may be normal initially, even if pulmonary injury has occurred Mild inhalational injury can be treated with supplemental oxygen, and consideration of albuterol or racemic epinephrine nebulizer treatment when wheezing or stridor are present, respectively Steroids are generally not recommended for treatment of burn patients with airway injury, although a single-center study showed no increased risk with a single dose Patients should continue to be monitored closely for any deterioration in their clinical status Significant inhalational injury will require endotracheal intubation and ventilatory support Extensive full-thickness burns of the thorax may restrict expansion of the chest and impair ventilation Respiratory insufficiency in this setting is an indication for escharotomy of the chest Incision through the depth of the eschar should be performed along the anterior axillary lines to allow adequate chest expansion If the deep burns extend to the abdomen, the escharotomies should be extended downward and connected by incision along the costal margin Circulation The rapid assessment of circulation includes skin color, capillary refill time, temperature of the peripheral extremities, heart rate, and mental status Blood pressure is often maintained until late in the course of shock, making it an unreliable early measure Hypertension from increased systemic vascular resistance has been reported immediately after severe burns, particularly in pediatric patients, and should not be taken as an indication to discontinue proper fluid therapy Vascular access should be obtained soon after the arrival of the child with severe burn injury Peripheral, large-bore intravenous catheters are favored because they have the lowest resistance Catheters placed in the upper extremity through intact skin are preferred because they are easier to secure, but access through burned areas may be necessary Anticipating the need for hyperalimentation, sites for central catheter placement should be saved, if possible Attention to aseptic technique when starting intravenous catheters in the emergency department (ED) can prevent infectious complications during subsequent care Circumferential taping is dangerous because the swelling that occurs during the first 24 hours can cause circulatory insufficiency distal to the constriction Urine output is the most important