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Difficulty: MediumTrauma and Burns

A 32-year-old male construction worker is brought to the emergency department after a high-voltage electrical injury. He was electrocuted by a live power line exactly 2 hours prior to arrival. On presentation, he is awake and reports severe pain. His vital signs show a blood pressure of 105/65 mm Hg, heart rate of 118/min, and respiratory rate of 20/min. Physical examination reveals deep, charred, full-thickness burns covering his entire right lower extremity, his entire left lower extremity, and his entire right upper extremity. His estimated body weight is 80 kg. A Foley catheter is placed, yielding dark brown urine.

Based on current Advanced Trauma Life Support (ATLS) guidelines for electrical burns, at what rate should the initial intravenous crystalloid infusion be set to deliver the appropriate resuscitation volume for the remainder of the first 8-hour period?

Answer: 1200 mL/hr

Answer

1200
The patient has a high-voltage electrical burn with clinical evidence of myoglobinuria (dark brown urine). Current ATLS guidelines mandate using 4 mL/kg/%TBSA for electrical burns to maintain high urine output and prevent pigment nephropathy. With a 45% TBSA burn (18% for each leg + 9% for the arm) and 80 kg weight, the 24-hour fluid need is 14,400 mL. Half of this total (7,200 mL) must be given in the first 8 hours from the time of injury. Since 2 hours have elapsed prior to arrival, the 7,200 mL must be infused over the remaining 6 hours, resulting in an infusion rate of 1,200 mL/hr.

Step-by-Step Solution

1
Select the correct resuscitation formula based on burn mechanism.
Use the ATLS electrical burn formula: 4 mL/kg/%TBSA.
High-voltage electrical burns cause deep muscle damage and rhabdomyolysis, leading to myoglobinuria (indicated by dark brown urine). Higher fluid volumes (4 mL vs standard 2 mL) are required to flush the kidneys and prevent acute kidney injury.
2
Calculate the Total Body Surface Area (TBSA) burned using the Rule of Nines.
TBSA = 18% (entire right leg) + 18% (entire left leg) + 9% (entire right arm) = 45%.
Accurate TBSA estimation is critical for the Parkland/ATLS fluid calculation.
3
Calculate the total 24-hour resuscitation volume.
4 mL × 80 kg × 45 = 14,400 mL.
This formula provides the estimated fluid requirement for the first 24 hours post-injury.
4
Determine the volume needed for the first 8 hours.
14,400 mL / 2 = 7,200 mL.
ATLS protocols require half of the total 24-hour calculated volume to be administered in the first 8 hours after the time of injury.
5
Calculate the remaining time for the first 8-hour infusion window.
8 hours - 2 hours (time since injury) = 6 hours remaining.
The 8-hour clock starts at the time of the burn, not the time of arrival at the hospital.
6
Calculate the hourly infusion rate.
7,200 mL / 6 hours = 1,200 mL/hr.
This is the continuous rate required to deliver the remaining first-half volume over the correct time period.

Key Concept

Fluid Resuscitation in Electrical Burns
Estimated Time:1m 30s
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Topics

Trauma and Burns

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