What is the recommended fluid resuscitation protocol for pediatric electrical burn patients?

Fluid Resuscitation for Pediatric Electrical Burn Patients

Pediatric electrical burn patients with ≥10% total body surface area (TBSA) burns should receive an initial bolus of 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour, followed by ongoing resuscitation guided by clinical response and urine output targets. 1

Initial Resuscitation Protocol

Immediate Fluid Administration (First Hour)

• Administer 20 mL/kg of isotonic crystalloid as an initial bolus within the first hour for any pediatric patient with electrical burns involving ≥10% TBSA 1
• Use balanced crystalloid solutions (Ringer's Lactate preferred) rather than 0.9% normal saline as first-line fluid, since balanced solutions reduce the risk of hyperchloremic metabolic acidosis and acute kidney injury compared to normal saline 1
• Establish intravenous access immediately, preferably in unburned areas; if peripheral access cannot be rapidly obtained, use intraosseous access 1

Critical Distinction for Electrical Burns

Electrical burns require special consideration beyond standard thermal burn formulas because:

• Electrical injuries cause deep tissue damage that may not be apparent from surface burn assessment alone
• Myoglobin release from muscle injury necessitates higher fluid volumes to prevent acute kidney injury
• Standard TBSA calculations underestimate actual tissue injury in electrical burns

Ongoing Resuscitation Strategy

Fluid Calculation After Initial Bolus

• Calculate ongoing fluid requirements using 4 mL/kg per % TBSA over 24 hours (Parkland formula), with half given in the first 8 hours from time of injury 1
• For children specifically, total fluid requirements may reach approximately 6 mL/kg per % TBSA over the first 48 hours 1
• Add maintenance fluid requirements using the Holliday-Segar formula (4 mL/kg/hr for first 10 kg, 2 mL/kg/hr for second 10 kg, 1 mL/kg/hr for each kg above 20 kg) to the calculated resuscitation volume 2

Titration Targets

• Target urine output of 1-2 mL/kg/hr in children (higher than standard 0.5-1 mL/kg/hr) when myoglobinuria is present from electrical injury 1
• Reassess after each fluid bolus for signs of adequate perfusion: improved mental status, capillary refill <2 seconds, heart rate normalization, and adequate urine output 3
• Discontinue or reduce fluid boluses if signs of fluid overload develop: increased work of breathing, rales/crackles, gallop rhythm, or hepatomegaly 3

Delivery Method

• Administer each 20 mL/kg bolus over 5-10 minutes using either a pressure bag (maintained at 300 mmHg) or manual push-pull technique with 10-20 mL syringes 3, 4, 5
• The 10-20 mL syringe sizes are optimal for manual push-pull delivery, providing fastest fluid administration with least hand fatigue 5
• Gravity-based fluid administration is inadequate for acute resuscitation and should not be used 4

Common Pitfalls and Caveats

Underresuscitation Risk

• Do not rely solely on surface TBSA calculations in electrical burns, as they dramatically underestimate actual tissue injury and fluid requirements
• Electrical burns often require significantly more fluid than predicted by standard formulas due to deep muscle and tissue damage
• Early aggressive resuscitation (up to 40-60 mL/kg in the first hour if needed) may be necessary for hemodynamic instability 3, 6

Overresuscitation Risk

• Frequent reassessment is mandatory to prevent fluid overload, which can lead to compartment syndrome, abdominal compartment syndrome, and pulmonary edema 1, 3
• Watch for development of increased intra-compartmental pressures requiring escharotomy, though this is rarely needed in the first 48 hours unless there is airway compromise 1

Monitoring Requirements

• Monitor urine output continuously (Foley catheter placement essential)
• Check urine for myoglobin (tea-colored urine indicates need for increased fluid administration)
• Serial assessment of peripheral perfusion, mental status, and vital signs after each bolus 3
• Consider early transfer to a burn center, as escharotomy should ideally be performed only at specialized centers 1

Special Considerations

• If urine remains dark/myoglobinuric despite adequate fluid resuscitation, consider adding sodium bicarbonate to alkalinize urine and mannitol as an osmotic diuretic (though this is beyond initial emergency management)
• For patients showing signs of ongoing instability after 40-60 mL/kg total fluid in the first hour, evaluate for other injuries (internal trauma, cardiac arrhythmias from electrical injury) 3
• Electrical burns may cause cardiac arrhythmias requiring continuous cardiac monitoring separate from fluid management considerations