A 35-year-old woman is brought to the emergency department after being caught in a house fire. She has no chronic medical conditions and no known allergies. Temperature is 35 C (95 F), blood pressure is 80/58 mm Hg, pulse is 156/min, and respirations are 35/min. Oxygen saturation is 67% on room air. The patient is disoriented. Black soot is seen in the nose and mouth. At least 50% of the body has burns, and there are full-thickness burns on the arms and legs. Intravenous access is obtained, and the patient is intubated and sedated due to signs of smoke inhalation and severe injuries. The wounds are cleaned, and topical antibiotics are placed over the burns. Which of the following is the most appropriate fluid management for this patient during the next 24 hours?

Question

A 35-year-old woman is brought to the emergency department after being caught in a house fire.  She has no chronic medical conditions and no known allergies.  Temperature is 35 C (95 F), blood pressure is 80/58 mm Hg, pulse is 156/min, and respirations are 35/min.  Oxygen saturation is 67% on room air.  The patient is disoriented.  Black soot is seen in the nose and mouth.  At least 50% of the body has burns, and there are full-thickness burns on the arms and legs.  Intravenous access is obtained, and the patient is intubated and sedated due to signs of smoke inhalation and severe injuries.  The wounds are cleaned, and topical antibiotics are placed over the burns.  Which of the following is the most appropriate fluid management for this patient during the next 24 hours?

Quizplus · Accepted Answer

11ec25c8_d913_c0a2_bc81_05d6fa21eda9_MD0003_00 Severe burn injuries often result in rapid development of intravascular volume depletion and shock due to both insensible fluid loss (due to decreased skin integrity) and massive fluid shift into the extravascular space (due to increased vascular permeability). Patients with extensive burns require aggressive fluid resuscitation to maintain tissue perfusion and reduce mortality. This is accomplished with the infusion of an isotonic crystalloid solution (eg, normal saline, lactated Ringer solution [LR]), which have similar osmolality to the blood (~288 mOsm/kg H₂O). Although these agents are equally effective at plasma volume expansion, LR, a balanced fluid, is preferred for resuscitation in burn victims. It contains near-physiologic levels of chloride, potassium, and calcium and includes sodium lactate, a buffer that is hepatically metabolized to bicarbonate, which helps correct acidosis and maintain normal blood pH. Normal saline is considered an unbalanced fluid because its chloride concentration is supraphysiologic (154 vs 103 mmol/L) and can cause a hyperchloremic metabolic acidosis. It has also been associated with hypocoagulability (Choice E). (Choices A and C) Dextrose 5% in water is initially a slightly hypotonic crystalloid solution that quickly becomes markedly hypotonic with the metabolism of dextrose; it is administered to patients with a free-water deficit (ie, hypernatremia). Half-normal saline is a hypotonic crystalloid that is also useful in treating hypernatremia. It is also used as a maintenance fluid in those unable to maintain adequate oral hydration and may be used after this patient has been adequately resuscitated. However, these solutions must be infused slowly because the low osmolality causes much of the fluid volume to shift into the intracellular space following infusion, which can result in cerebral edema. (Choice B) Fresh frozen plasma is a colloid solution that is indicated for replacement of coagulation factors (eg, diffuse intravascular coagulation, major bleeding on warfarin, massive transfusions). Colloids are less effective and more expensive than crystalloid solutions and not indicated for resuscitation for severe burns. Educational objective: Burn victims frequently develop intravascular volume depletion and require aggressive resuscitation with crystalloid solutions. Lactated Ringer solution, a balanced fluid, is preferred because it contains near-physiologic levels of electrolytes and includes a buffer that helps correct acidosis and maintain normal blood pH. Normal saline is associated with the development of hyperchloremic metabolic acidosis.

A 35-Year-Old Woman Is Brought to the Emergency Department After