Optimizing Emergency Management to Reduce Morbidity and Mortality in Pediatric Burn Patients (Trauma CME)

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Parkland Formula for Burns

• Introduction
• Points & Pearls
• Why and When to Use, and Next Steps
• Calculator Review Author
• Critical Actions
• Advice
• Evidence Appraisal
• Calculator Creator
• References
• Additional Reading

Introduction

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Points & Pearls

• The Parkland formula is a validated and effective approach to initial fluid resuscitation in the acutely burned patient.
• Overly aggressive fluid resuscitation, termed "fluid creep," is well documented in critical care literature. Factors that may lead to fluid creep include lack of physician observation of endpoints (ie, urine output), increased opioid use, and the emergency nature of goal-directed resuscitation.
• Patients with inhalational and electrical burns, as well as children and the elderly, may require more or less fluid resuscitation than is predicted by the Parkland formula.

Why and When to Use, and Next Steps

Calculator Review Authors

David Zodda, MD

Critical Actions

Critically ill burn patients are best cared for at a dedicated burn center, particularly those who have any of the following:

• Partial-thickness burns to > 10% of total body surface area. In pediatric patients, this can be calculated using the Rule of Nines for children: 9% for each arm, 14% for each leg, 18% for the head, 18% for the front torso, and 18% for the back torso. Alternatively, the Lund and Browder chart can be used to calculate an age-based estimation.
• Any size full-thickness burn
• Burns to hands or genitals Inhalation injury
• Serious chemical injury
• Serious electrical injuries, including lightning injury

Advice

It is important to remember that all resuscitation formulas should only be used as guides. Patients should be assessed frequently, with individual adjustments made to maintain adequate organ perfusion.

Evidence Appraisal

Blumetti et al (2008) conducted a retrospective study of patients resuscitated with the Parkland formula at a single institution over 15 years to determine the accuracy of the formula in guiding resuscitation. Using urine output as a guideline for adequate resuscitation, they found that patients commonly received fluid volumes higher than predicted by the Parkland formula, and concluded that the formula should represent a resuscitation “starting point,” but urine output is the most important parameter to control resuscitation volume.

Cartotto et al (2002) performed a retrospective study, and also found that the Parkland formula underestimated the volume requirements in most adults with burns, especially in those with large full-thickness burns. Thus, the Parkland formula is a validated and effective approach to initial fluid resuscitation in the acutely burned patient (Baxter 1974, Cartotto 2002, Blumetti 2008).

Calculator Creator

Charles Baxter, MD

References

Original/Primary Reference

• Baxter CR. Fluid volume and electrolyte changes in the early post-burn period. Clin Plast Surg. 1974;1:693-703.

Validation Reference

• Cartotto RC, Innes M, Musgrave MA, et al. How well does the Parkland formula estimate actual fluid resuscitation volumes? J Burn Care Rehabil. 2002; 23(4):258-265.

Other References

• Blumetti J, Hunt JL, Arnoldo BD, et al. The Parkland formula under fire: is the criticism justified? J Burn Care Res. 2008;29(1):180-186.
• American Burn Association Practice Guidelines. Available at: http://www.ameriburn.org. Accessed March 14, 2018.
• Ahrns KS. Trends in burn resuscitation: shifting the focus from fluids to adequate endpoint monitoring, edema control, and adjuvant therapies. Crit Care Nurs Clin North Am. 2004;16(1):75-98.
• Ahrns KS, Harkins DR. Initial resuscitation after burn injury: therapies, strategies, and controversies.  ACN Clin Issues. 1999;10(1):46-60.
• Jeng JC, Jablonski K, Bridgeman A, et al. Serum lactate, not base deficit, rapidly predicts survival after major burns. Burns. 2002;28(2):161-166.
• Hettiaratchy S, Papini R. Initial management of a major burn: II—assessment and resuscitation. BMJ.  004;329(7457): 101-103.