Severe burn injuries are medical emergencies that not only damage the skin but also disrupt fluid balance, leading to shock and potentially fatal complications. One of the most critical aspects of early burn care is fluid resuscitation—replacing the large amounts of fluid lost due to increased capillary permeability and evaporation from the wound surface.
To guide fluid therapy, healthcare professionals use standardized tools such as the Parkland Formula and the Rule of Nines. These methods allow quick, accurate calculations to determine how much intravenous fluid a burn patient requires in the first 24 hours after injury.
This article provides a complete guide to burn fluid resuscitation—covering the science behind it, how to calculate using the Parkland Formula, how to estimate body surface area using the Rule of Nines, worked examples, and key nursing considerations.
Why Fluid Resuscitation is Essential in Burns
Burns, especially second-degree (partial-thickness) and third-degree (full-thickness), cause capillary leakage where plasma and electrolytes escape into the interstitial space. This leads to:
- Edema formation
- Intravascular fluid loss (fluid volume deficit)
- Hypovolemic shock if untreated
Without rapid fluid replacement, patients can suffer:
- Decreased perfusion to vital organs
- Acute kidney injury
- Multi-organ failure
- Increased mortality
Thus, accurate and timely fluid resuscitation saves lives.
The Parkland Formula
Definition
The Parkland Formula is the most widely used method for calculating the amount of intravenous fluid required by burn patients in the first 24 hours after injury.
Formula
Key Points
Applies only to second- and third-degree burns (not first-degree).Calculated volume is given over 24 hours:
- First 8 hours: Half of total fluid volume
- Next 16 hours: Remaining half
Example
If a 70 kg adult has burns covering 30% TBSA:
- First 8 hours: 4,200 mL
- Next 16 hours: 4,200 mL
Rule of Nines
Purpose
The Rule of Nines is a quick method for estimating the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in adults.
Distribution
- Head and neck: 9%
- Each arm: 9% (front 4.5%, back 4.5%)
- Each leg: 18% (front 9%, back 9%)
- Anterior trunk: 18%
- Posterior trunk: 18%
- Perineum: 1%
This method is simple, rapid, and effective for emergency calculations.
Worked Example: Fluid Calculation
Case Study:
A 25-year-old male, weighing 79 kg, sustained burns to:
- Back of right arm (4.5%)
- Posterior trunk (18%)
- Front of left leg (9%)
- Anterior head and neck (4.5%)
Step 1: Calculate %TBSA burned
4.5 + 18 + 9 + 4.5 = 36% TBSA
Step 2: Apply Parkland Formula
Step 3: Divide Fluid Administration
- First 8 hours: 5,688 mL
- Next 16 hours: 5,688 mL
Answer: 11,376 mL total Lactated Ringer’s solution over 24 hours.
Monitoring During Fluid Resuscitation
While formulas provide an estimate, clinical monitoring is essential to ensure adequate resuscitation.
Vital Signs
- Maintain systolic BP > 100 mmHg
- Keep HR < 120 bpm
- Ensure adequate tissue perfusion
Urine Output (Most Reliable Indicator)
- Goal: 0.5–1 mL/kg/hr in adults
- Goal: 1–1.5 mL/kg/hr in children
Laboratory Parameters
- Monitor electrolytes (Na⁺, K⁺)
- Hematocrit levels
- Renal function (BUN/Creatinine)
Complications of Over- or Under-Resuscitation
- Under-resuscitation: Leads to hypovolemic shock, acute kidney injury, poor wound healing.
- Over-resuscitation (“fluid creep”): Causes pulmonary edema, abdominal compartment syndrome, cerebral edema.
Thus, titration based on patient response is as important as formula-based calculation.
Special Considerations
Pediatric Burns
- Children have different body surface area proportions (use Lund and Browder chart instead of Rule of Nines).
- Maintenance fluids with glucose are required alongside resuscitation fluids.
Electrical Burns
- Cause deep tissue damage and myoglobin release (rhabdomyolysis).
- Require larger fluid volumes to prevent acute kidney injury.
Elderly Patients
- Lower physiological reserve.
- Fluids must be adjusted carefully to avoid overload.
Comparative Table: Fluid Calculation Methods
| Method | Purpose | Advantage | Limitation |
|---|---|---|---|
| Parkland Formula | Calculates fluid requirement (24 hrs) | Simple, widely used | May under/overestimate, needs clinical monitoring |
| Rule of Nines | Estimates %TBSA | Quick, easy | Less accurate in children/obese |
| Lund and Browder Chart | Precise %TBSA | Accurate across ages | Requires time, not ideal for emergencies |
Frequently Asked Questions (FAQs)
Q1: What is the first priority in burn fluid resuscitation?
The first priority is maintaining airway and breathing, but fluid resuscitation becomes critical within minutes to hours to prevent shock.
Q2: Why is Lactated Ringer’s preferred over normal saline?
Lactated Ringer’s more closely matches extracellular fluid composition and prevents hyperchloremic acidosis caused by large amounts of normal saline.
Q3: How is fluid resuscitation different in children?
Children require the Lund and Browder chart for TBSA estimation and need maintenance fluids with glucose in addition to resuscitation fluids.
Q4: Why is urine output the best indicator of adequate resuscitation?
Because it reflects kidney perfusion and overall intravascular volume status better than blood pressure alone.
Q5: Can oral fluids replace IV fluids in burns?
In severe burns (>15–20% TBSA), oral intake is inadequate. IV fluid therapy is mandatory.
