A patient presents with burns to both his arms, chest, and abdomen (anteriorly only) from a flash fire. That’s about 27% total body surface area (TBSA). So how much IV fluid should be given?

Be aware of a phenomenon known as “fluid creep”, where patients actually get WAY too much IV fluids than they should, which can cause delayed complications such as ACS, pulmonary edema, and compartment syndrome. Don’t forget that patients often get a lot of IV fluids in the prehospital setting, which should also be factored in.

Two formulas are available to help guide fluid resuscitation. Using the Parkland versus modified Brooke formula have no clinical difference in outcome. 1

Parkland formula

  • Fluid requirements = TBSA burned (%) x Wt (kg) x 4 mL
  • Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours.

Modified Brooke formula

  • Fluid requirements = TBSA burned (%) x Wt (kg) x 2 mL
  • Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours.
Quick, at what rate should you order your IV fluids for your patient with 27% TBSA scald burns? It’s challenging to pull out your favorite medical calculator during the middle of your resuscitation. You should delegate this task to a team member. In the meantime …

Trick of the Trade

Use the rule of 10’s to start

  1. Estimate burn size to the nearest 10%.
  2. Multiply %TBSAx10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg).
  3. For every 10 kg above 80 kg, increase the rate by 100 mL/hr.

So let’s say we had patients of different weights with 27% burns, the calculated rates (mL/hr) for each of the approaches are:

Weight (kg)Mod BrookeParklandRule of 10’s
30101203n/a
40135270300
50169338300
60203405300
70236473300
80270540300
90304608400
100338675500

 

Note that the initial resuscitation rate with the rule of 10’s falls typically between the modified Brooke and Parkland formula values. This helps you avoid “fluid creep”.

Thanks to Dr. Natalie DeSouza (UCSF-SFGH EM resident) for this tip!

Additional Reading
  1. Dr. Cliff Reid’s Resus.Me post on Burns and Resuscitation (Oct 19, 2009)
1.
Chung K, Wolf S, Cancio L, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-7; discussion 237. [PubMed]
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD

@M_Lin

Professor of Emerg Med at UCSF-Zuckerberg San Francisco General. Founder of ALiEM @aliemteam #PostitPearls https://t.co/7v7cgJqNEn
Michelle Lin, MD