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Difficulty: HardTrauma and Burns

A 26-year-old man weighing 90 kg is brought to the emergency department 2 hours after being rescued from a house fire. On primary survey, his airway is patent, and he is breathing spontaneously on supplemental oxygen without evidence of inhalation injury. Vital signs include a blood pressure of 110/70 mm Hg, heart rate of 115/min, and respiratory rate of 18/min. Physical examination reveals deep partial-thickness burns with blistering over his entire anterior trunk, entire left arm, and the anterior surface of his left leg. The skin on his face is erythematous and highly sensitive to touch, but no blisters are present. Two large-bore intravenous catheters were placed at the scene, but no intravenous fluids have been administered yet.

Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what is the appropriate targeted intravenous fluid administration rate (in mL/hour) for the remainder of the first 8-hour period following the burn?

Answer: 540 mL/hour

Answer

540
The updated ATLS protocol for adult thermal burns dictates using 2 mL of lactated Ringer solution per kg of body weight per percentage of TBSA. TBSA calculations only include partial-thickness and full-thickness burns (anterior trunk 18% + left arm 9% + anterior left leg 9% = 36%). Superficial face burns are excluded. The 24-hour fluid total is 2 mL x 90 kg x 36% = 6,480 mL. Half of this volume (3,240 mL) is given in the first 8 hours from the time of injury. Since 2 hours have already passed, the 3,240 mL must be infused over the remaining 6 hours, resulting in a target rate of 540 mL/hour.

Step-by-Step Solution

1
Calculate the Total Body Surface Area (TBSA) affected by second- and third-degree burns using the Rule of Nines.
TBSA = 36%
The anterior trunk is 18%, the entire left arm is 9%, and the anterior left leg is 9%. Superficial (first-degree) burns, such as those on the patient's face, do not count toward TBSA for fluid resuscitation.
2
Calculate the total 24-hour resuscitation fluid requirement using the updated ATLS formula for adult thermal burns.
Total 24-hour fluid = 6,480 mL
The current standard is 2 mL x weight in kg x %TBSA. Therefore, 2 x 90 x 36 = 6,480 mL.
3
Determine the fluid volume required for the first 8-hour period post-injury.
First 8-hour volume = 3,240 mL
Exactly half of the total calculated 24-hour fluid must be administered within the first 8 hours following the exact time of the burn.
4
Calculate the appropriate hourly infusion rate based on the time elapsed since the injury.
Infusion rate = 540 mL/hour
The patient arrived 2 hours after the injury, leaving only 6 hours remaining in the initial 8-hour window. Dividing 3,240 mL by 6 hours yields 540 mL/hour.

Key Concept

Burn fluid resuscitation calculations must use the updated ATLS guidelines (2 mL/kg/%TBSA for adults), exclude superficial burns, and account for the time elapsed since the injury.

Alternative Method

An alternative mathematical shortcut is to calculate the initial 8-hour total directly as (1 mL x weight in kg x %TBSA), which yields 1 x 90 x 36 = 3,240 mL, and then divide by the remaining hours.
Estimated Time:2m 0s
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Topics

Trauma and Burns

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