Authors: Rami Mossad Ibrahim, MD, Elisabeth Lauritzen, MD, Frederik Gulmark, Hansen Med. Stud., Anne Mosebo, Med. Stud., Magnus Balslev Avnstorp, MD and Rikke Holmgaard, MD, PhD

Fluid resuscitation during the first 24 hours after a 2nd or 3rd degree burn can be calculated using the modified Parkland formula:  

Fluid resuscitation during the first 24 hours =
3 ml x weight in kg x burned percentage of TBSA*

*Total Body Surface Area

Indications for fluid resuscitation

Indications for fluid resuscitation depends on the age of the patient:

Adults ≥ 15 years	TBSA ≥ 20%
Children < 15 years	TBSA ≥ 10%

Administration of fluids

Intravenous input

50% of the fluids calculated by the Parkland formula are administrated within the first 8 hours and the remaining 50% is administrated within the next 16 hours. Fluid therapy should be calculated from the time of the injury and not from the patient is admitted to the hospital. Therefore it is important to aquire knowledge of prehodpital fluid treatment. Patients may eat and drink without restrictions.

Urine output

Input has to balance the output and should be adjusted according to the hourly urine output. To sustain a balance, a bladder catheter is indicated to measure the urine hourly output.

Urine output should be

Adults	0,5-1 ml/kg/hr
Children	1-2 ml/kg/hr

Reassessment of fluid administration:

The hourly diuresis is too high

• This can lead to oedema in the lungs, brain etc.
• This can reduce peripheral circulation and thus increase ischemia in the tissue

The hourly diuresis is small or decreasing

• Make sure of adequate administration and a well-functioning bladder catheter
• Reassess burn size and if inadequate make a new calculation of fluid treatment

The hourly diuresis remains small or decreasing

• Administer extra fluid as a bolus of Ringer lactate, 5-10ml/kg over 1 hour or by increasing the fluid administration to 150% for 1 hour
• If urine output continues low, albumin can be administered on the second day after injury. This increases the osmotic gradient across the vessel wall when the capillaries are no longer permeable to colloids, thus increasing the kidney filtration pressure resulting in greater diuresis
• Albumin 5% is administered intravenously according to the formula: 0.5 ml x kg x TBSA.

The 4:2:1 principle

Children should also receive fluid therapy during the first 24 hours after the burn injury. Fluid administration is calculated using the 4:2:1 principle. Lower physiological reserves causes a higher risk of developing hypoglycaemia. A supplement of fluids consisting of 0.9% NaCl with 5% dextrose is indicated. 

The dose is calculated according to weight:

Up to 10 kg	4 ml per kg
From 10-20 kg	2 ml per kg
>20 kg	1 ml per kg

Summary

The table below is a summary of the management of fluid resuscitation during the first 24 hours after a burn injury according to age.

	Formula	1. period (8 hours)	2. period (16 hours)
Adults ≥ 15 years	Parkland: 3 ml x weight in kg x % TBSA	50% of the calculated fluid	50% of the calculated fluid
Children < 15 years	Parkland: 3 ml x weight in kg x % TBSA + Maintenance fluid (4:2:1 principle)	50% of the calculated fluid	50% of the calculated fluid

Example

Child (<15 years) with a 2nd degree burn

• Weight: 25 kg
• Burned percentage of TBSA: 10%

Fluid is given according to the modified Parkland formula + maintenance fluid according to the 4:2:1 principle:

The Parkland formula

• 3 ml x 25kg x 10 % = 750 ml in total

The 4:2:1 principle:

• 4 ml x 10 kg = 40 ml/hour
• 2 ml x 10 kg = 20 ml/hour
• 1 ml x 5 kg = 5 ml/hour

Within the first 24 hours after burn injury, the child should be given:

• First period (0-8 hours after burn injury)
  • 50% of the calculated Parkland formula = 375 ml +
  • Supplemental fluid according to the 4:2:1 principle: 65 ml/hour
• Second period (9-24 hours after burn injury)
  • 50% of the calculated Parkland formula = 375 ml +
  • Supplemental fluid according to the 4:2:1 principle: 65 ml/hour

Acknowledgements

Illustrators: Anne Mosebo, Med. Stud.