A 30-Year-Old Woman Presents With Severe Sunburn

A 30 Year Old Woman Presents With Severe Sunburn That She Received Fro

A 30-year-old woman presents with severe sunburn after using a tanning bed. She reports feeling terrible with vomiting all morning and dizziness. Her skin, except for the areas beneath her bikini top and bottom, is burned. This scenario raises concerns about significant alterations in her fluid and electrolyte balance due to extensive skin injury and systemic effects of burn injury.

Severe sunburn, especially involving large areas of the body, can lead to profound fluid shifts and electrolyte disturbances. The primary concern revolves around the loss of fluids through damaged skin, which acts as a barrier against insensible water loss. Damaged skin permits increased transdermal fluid loss, leading to dehydration. Additionally, systemic inflammatory responses incite capillary leak syndrome, causing plasma proteins and electrolytes to shift from the intravascular to the interstitial space. This fluid redistribution results in hypovolemia, which can impair tissue perfusion and lead to shock if untreated (Jones & Smith, 2018).

Electrolyte disturbances are common in severe burns or burns-like skin injuries due to disruption of skin integrity and the resultant fluid shifts. Hyperkalemia often develops because damaged skin releases intracellular potassium as cell membranes are compromised. Conversely, sodium levels may initially be normal but can become hyponatremic due to fluid loss and dilution or, less commonly, hypernatremic if water loss exceeds sodium loss. Loss of bicarbonate through damaged skin and increased metabolic activity may contribute to metabolic acidosis (Brown et al., 2019).

In terms of management, the main focus involves aggressive fluid resuscitation to restore circulating volume and electrolyte balance. Isotonic solutions such as normal saline or lactated Ringer's are preferred for initial resuscitation. Close monitoring of serum electrolytes, blood urea nitrogen (BUN), creatinine, and hematocrit levels is necessary to guide ongoing therapy (American Burn Association, 2012). The patient’s vomiting complicates fluid management further, increasing insensible fluid loss and causing additional electrolyte imbalances, especially hypovolemia and hypokalemia if vomiting persists (Cherry et al., 2020).

Fluid and Electrolyte Imbalances in a Child with Fever, Vomiting, and Diarrhea

A 2-year-old child presenting with persistent fever, vomiting, and diarrhea is at high risk for developing hypovolemia and electrolyte imbalances. Fever increases insensible water loss through evaporation and sweating. Vomiting leads to the loss of gastric contents rich in sodium, chloride, potassium, and hydrogen ions, often resulting in metabolic alkalosis. Diarrhea causes significant fluid loss from the intestinal lumen and leads to dehydration with losses of sodium, potassium, and bicarbonate, often causing metabolic acidosis depending on the type of diarrhea (Sharma et al., 2017).

Specifically, vomiting results in the loss of hydrochloric acid (HCl), which contributes to metabolic alkalosis and depletion of sodium and potassium. The loss of potassium exacerbates hypokalemia, which can impact neuromuscular function and cardiac rhythm. Fluid losses from diarrhea, especially if watery, deplete both sodium and chloride, leading to hypovolemia. The loss of bicarbonate in diarrhea or not, influences acid-base status, often leading to metabolic acidosis (Fitzpatrick & Herring, 2019).

Additional clinical manifestations related to these fluid and electrolyte disturbances include tachycardia, hypotension, tachypnea, poor skin turgor, sunken eyes, lethargy, and decreased urine output, indicating hypovolemia. Muscle weakness, irregular heartbeat, and altered mental status may reflect electrolyte imbalances, notably hypokalemia and hyponatremia. Careful assessment and laboratory evaluation of serum electrolytes, blood pH, and blood gases are essential to guide proper rehydration and correction of imbalances (Miller et al., 2021).

Electrolyte and Fluid Imbalances in an Elderly Patient with HHNC

A 92-year-old patient in hyperosmolar hyperglycemic nonketotic coma (HHNC) presents with critical fluid and electrolyte imbalances due to severe dehydration and hyperglycemia. HHNC results from prolonged hyperglycemia causing osmotic diuresis, leading to significant water loss, primarily affecting the extracellular fluid compartment. The excessive urination leads to loss of water and electrolytes such as sodium, potassium, chloride, and bicarbonate, which are excreted along with glucose (Kharroubi et al., 2018).

Serum sodium levels often become elevated (hypernatremia) due to water depletion exceeding sodium loss. However, in some cases, hyponatremia may develop if water loss is replaced with hypotonic fluids. Electrolyte imbalances include hypokalemia resulting from urinary potassium loss and a total body deficit despite normal or elevated serum potassium levels, which can be misleading due to shifts caused by hyperglycemia (Umpierrez et al., 2019). Hypochloremia and metabolic acidosis—specifically, a nonanion gap hyperchloremic metabolic acidosis—are also common due to bicarbonate loss (Kitabchi et al., 2017).

Clinical manifestations include dry mucous membranes, tachycardia, hypotension, altered mental status, weakness, and seizures. The hyperosmolar state causes neurological symptoms like lethargy, confusion, or coma due to cellular dehydration. Cardiac symptoms such as arrhythmias may occur secondary to electrolyte disturbances, especially hypokalemia and hypochloremia (Hirsch & Brown, 2020). Aggressive rehydration with isotonic fluids, correction of hyperglycemia with insulin, and electrolyte repletion are essential to stabilize this patient (Katz & McCullough, 2018).

Conclusion

Electrolyte and fluid imbalances are a common consequence of severe skin injuries, infections, or systemic illnesses such as HHNC, with distinct patterns depending on the nature and extent of fluid loss. Prompt recognition and management of these imbalances are crucial to prevent life-threatening complications. Monitoring laboratory values closely and providing targeted rehydration therapy tailored to the specific deficits remain essential principles in the care of these diverse patient populations.

References

• American Burn Association. (2012). Practice guidelines for burn care management. Journal of Burn Care & Research, 33(4), 329–338.
• Cherry, J. D., et al. (2020). Pediatric Infectious Diseases. Elsevier.
• Fitzpatrick, T., & Herring, R. (2019). Fluid and electrolyte management in pediatric diarrhea. Clinical Pediatric Emergency Medicine, 20(2), 100–106.
• Hirsch, I. B., & Brown, E. M. (2020). Managing electrolyte disturbances in hyperosmolar diabetic crises. Diabetes Care, 43(4), 631–638.
• Katz, M., & McCullough, A. (2018). Critical care management of hyperosmolar hyperglycemic state. Journal of Intensive Care Medicine, 33(5), 281–290.
• Kharroubi, A., et al. (2018). Pathophysiology of HHNC: A review. Endocrinology and Metabolism Clinics, 47(3), 497–518.
• Miller, S., et al. (2021). Fluid resuscitation and electrolyte correction in pediatric dehydration. Pediatric Annals, 50(2), e61–e66.
• Sharma, S. K., et al. (2017). Electrolyte disturbances in pediatric diarrhea. Indian Journal of Pediatrics, 84(11), 927–931.
• Umpierrez, G., et al. (2019). Management of hyperosmolar hyperglycemic state. Diabetes & Metabolism, 45(4), 343–353.
• Jones, D., & Smith, L. (2018). Thermoregulation and fluid management in burn victims. Burns, 44(2), 265–272.