Fluid resuscitation
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
- To measure input and output all patients must have a fluid schedule and bladder catheter
- Be aware of symnptoms such as confusion, restlessness or anxiety – may be due to hypovolemia. These symtoms indicate a re-evaluation and reassessment of fluid therapy and urine output
Acknowledgements
Illustrators: Anne Mosebo, Med. Stud.