Fluid resuscitation should be commenced with two large-bore intravenous lines (IVs) infusing Ringer's lactate or normal saline. If possible, an IV should not be started on an extremity that was part of the current pathway, because delayed thrombosis may occlude the infusion line. Fluid requirements for victims of electrical burns are higher than the fluid requirements for victims of thermal burns, and formulas based on percent of body surface area involved will not provide enough volume to avert rhabdomyolysis and maintain tissue perfusion. An initial fluid challenge of 20 to 40 mL/kg over the first hour is appropriate for most patients. Further fluid requirements are guided by clinical and hemodynamic assessment. Central venous or pulmonary artery pressure monitoring may be necessary to guide fluid replacement and avoid volume overload in patients at risk for congestive heart failure.
Rhabdomyolysis with myoglobinuria should be treated with urinary alkalization; 44 to 50 meq of sodium bicarbonate added to each liter of intravenous (IV) fluid. Blood pH should be maintained 7.45 or greater and urine output at 1.5 to 2.0 mL/kg/h. IV mannitol may be administered to encourage urine flow at an initial dose of 25 g in adults and 0.5 to 1 g/kg in children. Mannitol infusions may be given until the urine is free of myoglobin, but it is very important that patients not become hypovolemic. If thermal burns are also present, mannitol should not be given, due to the risk of hypovolemia. (See Chapi 271, "Rhabdomyolysis.")
Wound care for minor localized and partial-thickness wounds consists of cleansing and application of silver sulfadiazine. Full-thickness burns with an eschar are better treated with mafenide acetate, because it penetrates eschar well. Side effects from mafenide are metabolic acidosis and pain with application. Tetanus prophylaxis should be administered as indicated. For patients with extensive muscle damage and soil contamination, the risk of tetanus is such that tetanus immune globulin should be considered even if the patient's tetanus immunizations are up to date. There is no scientific evidence to support the prophylactic administration of parenteral antibiotics (e.g., high-dose penicillin) to prevent clostridial infection in patients with extensive devitalized tissue.
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