Aggressive Fluid Resuscitation with Lactated Ringer's Solution
The correct answer is D: lactated Ringer's. This patient with electrical burns and evidence of myoglobinuria requires aggressive fluid resuscitation with balanced crystalloid solution to maintain high urine output (100 mL/hour or 1-2 mL/kg/hour) to prevent myoglobin-induced acute kidney injury. 1, 2
Why Lactated Ringer's is the Treatment of Choice
Electrical burns cause extensive deep tissue destruction and muscle damage that is far more severe than the visible surface burns suggest. 1, 2 This patient's urinalysis likely shows myoglobinuria (though not explicitly stated in the question, this is the critical finding in electrical injuries that guides treatment).
Specific Fluid Management Protocol
- Administer balanced crystalloid solution (Ringer's Lactate preferred) using the modified Parkland formula of 3-4 mL/kg/%TBSA for electrical burns 1
- Target urine output of 100 mL/hour (or 1-2 mL/kg/hour) specifically for electrical burns with myoglobinuria - this is higher than the standard 0.5-1 mL/kg/hour used for thermal burns 1, 2
- The higher urine output target is essential to overcome the destructive renal tubular effects of myoglobin and hemoglobin products 2
- Maintain normal vital signs and aggressive circulatory volume replacement 2
Why the Other Options Are Wrong
A. Furosemide is contraindicated: Diuretics would worsen hypovolemia and do not address the underlying need for aggressive volume resuscitation. The goal is to dilute and flush myoglobin through the kidneys with high-volume crystalloid, not to force diuresis. 1, 2
B. Hemodialysis is premature: While electrical burns can cause acute kidney injury requiring dialysis, this patient has stable vital signs (BP 126/80) and no indication of established renal failure requiring immediate dialysis. The priority is preventing AKI through aggressive fluid resuscitation. 3, 4
C. Heparin has no role: There is no indication for anticoagulation in acute electrical burn management. While small vessel occlusion contributes to progressive tissue destruction, the immediate priority is fluid resuscitation to prevent myoglobin-induced renal injury. 2
Critical Pitfalls to Avoid
- Do not underestimate fluid requirements in electrical burns - the visible 15% TBSA burn significantly underrepresents the true extent of deep tissue injury 1, 2
- Electrical burns cause deeper tissue damage than apparent on surface examination, particularly to periosseous muscle and tissues along the current pathway 2, 4
- Monitor for compartment syndrome - this patient with torso and leg burns is at high risk and may require fasciotomy/escharotomy 1, 4
- Avoid normal saline as primary resuscitation fluid - it increases risk of hyperchloremic metabolic acidosis and acute kidney injury compared to balanced solutions 3, 1
Additional Monitoring Considerations
- Serial muscle biopsies and technetium Tc 99m pyrophosphate uptake can help determine nonviable tissue requiring debridement 2
- Progressive tissue destruction may continue for days due to small vessel occlusion 2
- Multiple organ systems are often affected in electrical injuries, making treatment exceptionally challenging 4