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.