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Difficulty: Very hardTrauma and Burns

A 32-year-old man is brought to the emergency department via ambulance after being rescued from a house fire. He weighs 100 kg. The fire started at 13:00, and he was extricated shortly after. He arrives at the emergency department at 16:00. Physical examination reveals deep partial-thickness and full-thickness thermal burns involving his entire back, entire right arm, entire left arm, and the anterior surface of his right leg. During transport, emergency medical services administered 900 mL of intravenous Lactated Ringer's solution. Vital signs are blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 22/min. Assuming adherence to the most current Advanced Trauma Life Support (ATLS) recommendations for adult thermal burn fluid resuscitation (2 mL×weight in kg×%TBSA2 \text{ mL} \times \text{weight in kg} \times \%\text{TBSA}), what should be the intravenous fluid infusion rate (in mL/hr) programmed on the pump for the remainder of the first 8-hour resuscitation window?

Answer: 720 mL/hr

Answer

720
The patient requires a total of 9,000 mL for 24 hours based on the current ATLS formula (2×100×452 \times 100 \times 45). Exactly half of this total (4,500 mL) is indicated for the first 8 hours post-injury. Because 3 hours have already passed since the injury and 900 mL has already been administered by EMS, the remaining 3,600 mL must be infused over the remaining 5 hours. Therefore, the pump must be set to 720 mL/hr.

Step-by-Step Solution

1
Calculate the total body surface area (TBSA) burned using the Rule of Nines.
TBSA = 45%.
Entire back (18%) + right arm (9%) + left arm (9%) + anterior right leg (9%) = 45%.
2
Calculate the total 24-hour fluid requirement using the provided ATLS formula.
Total fluid = 9,000 mL.
2 mL×100 kg×45%=9,000 mL2 \text{ mL} \times 100 \text{ kg} \times 45\% = 9,000 \text{ mL}.
3
Determine the fluid requirement for the first 8 hours.
First 8-hour requirement = 4,500 mL.
Half (50%) of the total 24-hour fluid must be administered in the first 8 hours post-injury.
4
Account for the pre-hospital fluids already administered.
Remaining volume needed = 3,600 mL.
4,500 mL−900 mL (given by EMS)=3,600 mL4,500 \text{ mL} - 900 \text{ mL} \text{ (given by EMS)} = 3,600 \text{ mL}.
5
Calculate the time remaining in the first 8-hour window.
Remaining time = 5 hours.
The first 8 hours is calculated from the time of the burn injury (13:00), not the time of arrival. At 16:00, 3 hours have elapsed, leaving 8−3=58 - 3 = 5 hours.
6
Calculate the final infusion rate in mL/hr.
Rate = 720 mL/hr.
3,600 mL/5 hours=720 mL/hr3,600 \text{ mL} / 5 \text{ hours} = 720 \text{ mL/hr}.

Key Concept

Accurate burn resuscitation calculations must account for the correct %TBSA, the time elapsed since the actual injury, and any pre-hospital fluid volume already administered.
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Topics

Trauma and Burns

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