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Difficulty: HardTrauma and Burns

A 29-year-old male utility worker is brought to the emergency department after sustaining a high-voltage electrical injury while working on a power line. The injury occurred exactly 3 hours ago. On presentation, he has full-thickness burns involving his entire anterior trunk, entire right arm, entire left arm, and the anterior surface of his right leg. The remainder of his skin is uninjured. He weighs 90 kg. During transport, emergency medical services established intravenous access and administered 1,100 mL of lactated Ringer solution. According to the Advanced Trauma Life Support (ATLS) guidelines for electrical burns, what should be the intravenous fluid infusion rate (in mL/hr) for the remainder of the first 8-hour resuscitation period?

Answer: 1400 mL/hr

Answer

1400
The correct infusion rate is 1,400 mL/hr. Using the Rule of Nines, the TBSA is 45% (anterior trunk 18%, right arm 9%, left arm 9%, anterior right leg 9%). For high-voltage electrical burns, the ATLS fluid resuscitation formula is 4 mL * kg * %TBSA. The total 24-hour requirement is 4 * 90 * 45 = 16,200 mL. Half of this (8,100 mL) must be given in the first 8 hours from the time of injury. Since 3 hours have passed, there are 5 hours remaining in this window. The patient already received 1,100 mL from EMS, leaving a required volume of 7,000 mL (8,100 - 1,100). Dividing 7,000 mL by the remaining 5 hours yields 1,400 mL/hr.

Step-by-Step Solution

1
Calculate the Total Body Surface Area (TBSA) affected by the burn.
18% + 9% + 9% + 9% = 45% TBSA.
The Rule of Nines is used to estimate the extent of burns to accurately calculate fluid requirements.
2
Calculate the total 24-hour fluid resuscitation requirement.
4 mL * 90 kg * 45% = 16,200 mL.
ATLS guidelines mandate 4 mL/kg/%TBSA for high-voltage electrical burns (unlike the 2 mL/kg/%TBSA standard for adult thermal burns) to prevent pigment-induced nephropathy from myoglobinuria.
3
Determine the fluid target for the first 8 hours post-injury.
16,200 mL / 2 = 8,100 mL.
Half of the total 24-hour fluid requirement must be given in the first 8 hours from the time of the injury.
4
Calculate the remaining fluid needed for the first 8-hour window.
8,100 mL - 1,100 mL = 7,000 mL.
The patient already received 1,100 mL from EMS, which must be subtracted from the first 8-hour target to avoid fluid overload.
5
Calculate the infusion rate for the remaining time.
7,000 mL / 5 hours = 1,400 mL/hr.
The injury occurred 3 hours ago, leaving 5 hours in the first 8-hour window. The remaining volume is divided by the remaining time.

Key Concept

Fluid resuscitation in electrical burns requires 4 mL/kg/%TBSA, with half administered in the first 8 hours from the time of injury, accounting for any pre-hospital fluid given and elapsed time.
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Topics

Trauma and Burns

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