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Zorluk: OrtaTrauma and Burns

A 35-year-old electrical lineman is brought to the emergency department after sustaining a high-voltage electrical injury from a power transformer. The accident occurred exactly 2 hours prior to his arrival due to extrication difficulties. He is awake but confused. His blood pressure is 140/85 mm Hg and his heart rate is 112/min. A Foley catheter is placed and immediately drains dark, tea-colored urine. He weighs 90 kg. Physical examination reveals deep entry and exit wounds on his upper extremities, as well as associated full-thickness thermal burns covering exactly 20% of his total body surface area (TBSA).

According to the current Advanced Trauma Life Support (ATLS) guidelines for electrical burns, what should be the initial intravenous fluid infusion rate (in mL/hr) of lactated Ringer solution upon his arrival?

Cevap: 600 mL/hr

Cevap

600
The correct initial fluid rate is 600600 mL/hr. Patients with high-voltage electrical injuries are at significant risk for rhabdomyolysis and subsequent myoglobinuric acute renal failure (indicated by the tea-colored urine). Therefore, the current Advanced Trauma Life Support (ATLS) guidelines mandate a higher fluid resuscitation volume of 44 mL/kg/%TBSA for electrical burns, compared to 22 mL/kg/%TBSA for standard thermal burns. For this patient, the 24-hour fluid requirement is 4×90 kg×20%=72004 \times 90 \text{ kg} \times 20\% = 7200 mL. Half of this total volume (36003600 mL) must be infused within the first 88 hours from the time of injury. Because the patient presented 22 hours post-injury, the remaining time to infuse this volume is 66 hours. The required infusion rate is 36006=600\frac{3600}{6} = 600 mL/hr.

Adım Adım Çözüm

1
Identify the appropriate formula for electrical burns.
44 mL/kg/%TBSA
Current ATLS guidelines recommend 44 mL/kg/%TBSA for electrical burns (unlike thermal burns, which use 22 mL) to increase urine output and prevent pigment nephropathy from myoglobinuria.
2
Calculate the total 24-hour fluid requirement.
72007200 mL
Using the formula: 4×90 kg×20%=72004 \times 90 \text{ kg} \times 20\% = 7200 mL.
3
Determine the fluid volume required for the first 8 hours.
36003600 mL
Half of the calculated 24-hour total volume is administered in the first 8 hours post-injury. 72002=3600\frac{7200}{2} = 3600 mL.
4
Adjust the timeline for the delayed presentation.
66 hours remaining
The fluid resuscitation timeline starts from the exact time of the injury. Since the patient arrived 22 hours after the incident, there are 8−2=68 - 2 = 6 hours remaining to infuse the initial half of the fluids.
5
Calculate the initial hourly infusion rate.
600600 mL/hr
Divide the required volume by the remaining hours in the initial 8-hour window. 36006=600\frac{3600}{6} = 600 mL/hr.

Anahtar Kavram

Fluid resuscitation in electrical burns requires 44 mL/kg/%TBSA, and the initial infusion rate must be adjusted for any time elapsed since the injury.
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Trauma and Burns

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