What is The Parkland Formula?

Here’s a (fairly) simple calculation that you can use to figure out just how much fluid you should be giving to your burn patient. The Parkland formula is both simple and useful. It not only gives us a good general idea how fast we should administer that first bag of saline enroute to the E.R., it’s also a great reminder of an important fact of burn care:

Burn patient’s need lots of fluid. …How much?

Let’s review the Parkland Formula and figure it out.

The Parkland Formula was born in 1968 when emergency room physician Charles Baxter realized that his critical burn patients needed massive amounts of fluid in the first 24 hours of treatment to remain hemodynamically stable. Working out of Parkland Memorial Hospital in Dallas, Texas, he and his fellow physicians began experimenting to figure out a fast way to know just how much fluid was enough.

The result was the Parkland Formula. Used today almost universally, in burn centers across America and around the world, it has become a standard of critical burn care. And, yes, you can do it too. Don’t get nervous about your protocols, your local E.R. physician knows the formula.

The Parkland formula begins with a rough calculation of the patients total body surface area burned. That is to say, what percentage of the patients total body surface area is involved in the burn? To come up with that number we can use a few techniques. There’s the palm rule (or palmar rule) and the rule of nines. Feel free to brush up on both. We’ll wait.

OK, now that we know the total body surface area burned (TBSA) we also need to estimate the patient’s body weight in kilos. This is a relatively simple matter for just about everyone in the entire industrialized world…except within the United States. Here in the states we insist on teaching, learning and using the English standard system of measurement, which gives all of us in the medical field fits. There are a few good techniques for learning to estimate body weight in kilograms. You may want to review those too.

Now back to our Formula.

With the Parkland Formula, we’re only estimating second and third degree burn involvement. First degree burns don’t tend to create the massive fluid shifts that we see in second and third degree burns so we don’t administer fluids to them nearly as aggressively as we do for our more significant burn patients.

With that said, let’s take a look at the formula and then let’s use it in a couple of real burn scenarios. The calculation looks like this:

(4 * Patient’s weight in kilos * Percent of body area with second and third degree burns) = Amount of fluid to administer in the first 24 hours after burn injury.

Fluid to administer in first 24 hours divided by 2 = fluid to administer in first 8 hours

Finally, if we divide the final number by 8, we’ll know about how much fluid our patient should receive from us before we reach the hospital (in most urban EMS systems).

Don’t panic, it isn’t as complicated as it sounds. Let’s try it out.

A 220 pound male has second and third degree burns on his whole chest and abdomen, the front of both legs and the front of his right arm. Using the rule of nines we determine that the patient has approximately 40% of his total body surface area involved in the burn.

Chest + abdomen = 18%, whole leg = 18%, half of one arm = 4.5%. 18+18+4.5= 40.5%

We also calculate that his 220 lbs. puts him at exactly 100 kg. 220/2.2=100.

For this patient, our Parkland calculation would look like this: 4*100*40=16,000.

This patient will need 16,000 ccs of fluid, or 16 one liter bags in the first 24 hours of care. Divided that in half and we see that we’ll need to administer 8 liter bags in the first 8 hours. This patient needs a bag of fluid for ever hour of care that we provide.

Start your time calculation at the estimated time of the burn injury.

Do you feel like you have a handle on that one? Let’s take it up a notch.

This time lets take a 138 pound female with second degree circumferential burns to both her legs. Let’s also include her full back and the back of her head in the affected burn area. That would be 57.5% of her total body surface area.

Upper and lower back = 18%, Left whole leg = 18%, Right whole leg = 18%, back half of the head 4.5%. 18+18+18+4.5 = 58.5%

Now let’s convert her body weight to kilograms. 138 / 2.2= 62 kilos (more or less).

Now we’re ready to do our Parkland formula. 4*58*62= 14,384. With our first patient, many of us could manage the math in our heads. For our second patient, most of us would prefer a calculator near by.  Luckily, most of us carry a cell phone with a calculator function in our pockets. Make good use of it.

Our burned female will need about 14 litters of fluid in the first 24 hours of care with 7 coming in the first 8 hours. Between 800 and 900 ccs will do her just fine in transport.

We can see a few good uses for the Parkland formula. First, by playing with the calculation now, on hypothetical patients, we remind ourself of an important fact of burn care. Burned patients need a lot of fluid. Second, if we’re nervous about opening up that IV bag during transport, it’s simple enough to be used right there in the back of the medic unit to make a quick guess about how much fluid we should be giving enroute to the ER.

It’s important to note that the Parkland formula isn’t the last word in a burn patients fluid resuscitation. The formula is a fast way to develop a good idea just how much fluid a patient will ultimately need. As patient treatment progresses, unine output and vital signs will give care givers more accurate information about the effectiveness of the ongoing fluid resuscitation efforts. Retrospectively, the formula tends to be accurate in 70-80% of cases. Others will need adjustments along the way.

There you have it. Play with the Parkland formula and let me know what you think.

Comments

  1. Andrew Przepioski says:

    18+18+18+4.5 = 58.5, you accidentally typed 57.5.

    A pretty common trick I like to use for converting lbs to kg is to divide the number by 2, then subtract a 10th (10%) of that.

    For example, 150 lbs patient. 150/2 = 75. Then subtract a 10% (75 x 0.10 = 7.5) so 75 – 7.5 = 67.5. You’ll get a number that’s pretty close to diving by 2.2.

    I had a chat with someone about Parkland formula about two months ago, and he was saying that Parkland formula is becoming phased out as a golden standard because it’s consider to be too little, and in the ICU, they use other accurate indicators (albumin levels, bicarb, creatinine, electrolytes, OH) instead to determine how much fluids the patient needs. I don’t know where he got that information in regard to it being too little,I’ll have to ask him, a quick Google search showed otherwise (http://www.ncbi.nlm.nih.gov/pubmed/18182919 I found just a moment after trying to look that up), but it seemed to agree with him in regard to using other indicators instead of the foruma, but prehospitally and initially, I can see Parkland formula being useful since I don’t think most services have the ability to check those.

    Thank you for sharing.

  2. Why would you divide the 24 hr number by 2 to get the 8 hr number. Shouldn’t you be dividing it by 3?

  3. @Brett: Its because the first 8 hours require more aggressive fluid resuscitation than the last 16 hours.

  4. Andrew, Your friend is right. The Galveston formula is seen as the gold standard, especially with peds, but to use it, you need to figure BSA (body surface area), so Parkland is still useful prehospital.

    Brett, Parkland formula says the patient gets 1/2 of the total IVF in the first 8 hours, the last 1/2 in the next 16 hours. That’s why you divide the total in half, rather than thirds. Hope this helps.

  5. If i reached the hospital after 2 hours of burn, then how to apply dose concentration with parkland formula?

  6. what fluid would be most recommended for this patient?

  7. There is a controversy on whether the palm (only) or the hand (palm + fingers) method represents closer to 1% of TBSA. Which method do you prefer?

  8. does parkland formula use for fourth degrees burns or only for 3 &2?

  9. It’s a life-saving formula!
    Thank you for it!!!

  10. This is all explained with such clarity in comparison to nursing texts. Thank you.

  11. is there any possibility that the first 8 hour changing? or is there any cases that first 8 hours change more than 8 hour or maybe less than 8 hour depend on patient’s condition?

  12. How can you manage fluid if the patient’s body weight is not known? Because every know formula for fluid resuscitation needs body weight of the patient.

  13. Resurrecting this discussion! I’m on the ambulance so it would be almost impossible to give too much fluid. Guessing pt’s weight also doesn’t make that much of a difference initially. However, once they make it to definitive care they will have scales to take care of that. Does anyone know if different fluids are better/ worse for burns? Maybe something like hextend or a starch based fluid to help it stay in the circulation longer?

  14. Lactated Ringer’s is used most commonly in fluid resuscitation, due to its contents: calcium, potassium, sodium, chloride. LR replaces the electrolytes lost in the injury and it is the closest concentration to blood plasma.

  15. Rachel says:

    #1. Thank you for this!!! :o)
    #2. Lactated Ringers is given instead of colloids for the initial treatment, due to less risk of adverse effects, per my recorded nursing school lecture and book. But… they do not explain what those adverse effects are or the pathophys behind it. From a quick online search, I suspect that it has to do with vasodilation/ hypotension and also coagulability maybe. Can you shed any light on that issue? Thanks again!

  16. Ravikanth says:

    Please let me know how much fluid to give for 50 percent first degree burns .

  17. @ Ravinkanth – first degree burs do not cause the fluid shift (i.e. fluid loss) as the second degree and thrid degree do. Therefore, even though a bad suburn is bound to need rehydration, a simple KVO is preferential.
    @Rachel- LR is given because it replinishes the salts which are much need to help avoid the fluid shifting. At one point in time, D5W was given, but then quickly realized LR is the preferred treatment.
    @LesM- the standard used by most all Advaced Lifesupport Trauma and Burn courses are 1% = the patient’s palm.
    @ael myie- for now, there is little chaging about the formula. Vast studies were performed to develop a timeline (in other words many did not survive) for fluid resuscitation.
    My one piece of advice- AGGRESSIVE AIRWAY MANAGEMENT. If you’re patient is burned badly enough for you to use the Parkland Formula, you need to also focus on the airway
    @hesam- the Parkland formula stays the same for most patients once they cross the second degree burn level. Due to the severity of fourth, fifth, and sixth degree burns (bone being incinerated) in the field, anything above a second degree needs fluid. Massive fluid as prescribed in the Parkalnd formula. 4th, 5th, & 6th need a burn team and fast to improve mortality.

  18. I put a Parkland Formula calculator together that may help. You can also get a Google Docs spreadsheet on the website that you can use or download for yourself. It does all the calculations for you. Hope this helps.

  19. Nathaniel says:

    I was wondering how giving an initial fluid bolus for resuscitative purposes affects the formula. Do we subtract the bolus fluid volume from the total amount of fluid we calculated that we need to infuse over 24 hours?

    Thanks

  20. Anonymous says:

    its help me on exam thank you !

  21. rajankumar.t says:

    What is.maximum weight and maximum % we can take 2 calculate parkland formulj

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