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Difficulty: Very hardTrauma and Burns

A 42-year-old man weighing 90 kg is brought to the emergency department via ambulance after being involved in an industrial boiler explosion and fire. The incident occurred exactly 3 hours prior to arrival. He has a patent airway and his respirations are unlabored. Physical examination reveals erythema, blistering, and severe pain over the entire anterior torso and the entire posterior torso. The entire right lower extremity demonstrates leathery, charred, and insensate skin. Both upper extremities exhibit painful, blanching erythema with no blistering. During transport, emergency medical services established peripheral intravenous access and administered exactly 1260 mL of lactated Ringer solution.

Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should the infusion rate (in mL/hour) of lactated Ringer solution be set to for the remainder of the first 8 hours post-injury?

Answer: 720 mL/hr

Answer

720
The patient requires a correctly modified ATLS thermal burn calculation. Superficial burns on the arms are excluded, yielding a TBSA of 54% (18% + 18% + 18%). Using 2 mL/kg, the total 24-hour need is 9720 mL. Half (4860 mL) is due in the first 8 hours. Subtracting the 1260 mL given by EMS leaves 3600 mL. Because 3 hours have passed since the injury, 5 hours remain in the first 8-hour block. Dividing 3600 mL by 5 hours results in an infusion rate of 720 mL/hr.

Step-by-Step Solution

1
Evaluate burn depths to determine inclusion in the TBSA calculation.
Anterior and posterior torso (partial-thickness) and right leg (full-thickness) are included. Arms (superficial) are excluded.
Only second-degree (partial-thickness) and third-degree (full-thickness) burns are included in fluid resuscitation calculations.
2
Calculate the applicable TBSA using the Rule of Nines.
18% (anterior torso) + 18% (posterior torso) + 18% (right leg) = 54% TBSA.
Accurate estimation of affected surface area is required for the resuscitation formula.
3
Calculate the total 24-hour fluid requirement using current ATLS guidelines.
2 mL * 90 kg * 54% = 9720 mL.
ATLS 10th edition changed the formula for adult thermal burns to 2 mL/kg/%TBSA (from the older 4 mL/kg formula).
4
Calculate the target fluid volume for the first 8 hours.
9720 mL / 2 = 4860 mL.
Half of the calculated 24-hour fluid requirement must be administered during the first 8 hours post-injury.
5
Account for fluids already given and the time already elapsed since the injury.
Remaining fluid = 4860 mL - 1260 mL = 3600 mL. Remaining time = 8 hours - 3 hours = 5 hours.
The 8-hour window begins at the time of injury, not time of arrival, and prehospital fluids count toward the total.
6
Calculate the precise pump rate.
3600 mL / 5 hours = 720 mL/hr.
The remaining required fluid must be distributed evenly over the remaining time in the first 8-hour window.

Key Concept

Fluid resuscitation for adult thermal burns requires calculating TBSA excluding superficial burns, applying the updated ATLS formula (2 mL/kg/%TBSA), and strictly basing the infusion timeline on the time of injury while subtracting prehospital fluids.
Estimated Time:3m 0s
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Topics

Trauma and Burns

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