What is the ATLS (Advanced Trauma Life Support) modified Parkland formula for fluid resuscitation in burn patients?

ATLS Modified Parkland Formula (Edition 10)

The ATLS Edition 10 modified Parkland formula for burn resuscitation is 2-4 mL/kg/% TBSA of Lactated Ringer's solution over 24 hours, with half given in the first 8 hours post-burn and the remaining half over the next 16 hours. 1, 2, 3

Formula Components

• Volume calculation: 2-4 mL/kg/% TBSA burned over 24 hours 1, 2, 3
• Fluid type: Lactated Ringer's solution (preferred balanced crystalloid) 2, 3
• Timing:
  • 50% of calculated volume in first 8 hours from time of burn
  • Remaining 50% over next 16 hours 1, 2, 3

Patient Selection for Formal Resuscitation

• Adults: Burns ≥10% TBSA require formal fluid resuscitation 3
• Pediatric patients: Burns ≥10% TBSA require formal resuscitation (some sources suggest ≥5% TBSA) 1, 3

Initial Management

• Administer 20 mL/kg balanced crystalloid bolus in the first hour regardless of burn size to address early hypovolemic shock 1, 3
• Establish IV access immediately, preferably through unburned tissue 1, 3

Pediatric Modifications

• Pediatric formula: 3-4 mL/kg/% TBSA (higher end of the range) 1, 2
• Children require proportionally more fluid than adults due to higher surface area-to-weight ratio 2, 3
• Use 4 mL/kg/% TBSA for deep partial thickness or full thickness burns 1, 2

Resuscitation Targets

• Urine output:
  • Adults: 0.5-1 mL/kg/hour 1, 3
  • Pediatrics: 0.5-1 mL/kg/hour 1, 2
• Electrical burns with myoglobinuria: Target 1-2 mL/kg/hour to prevent acute kidney injury 3

Critical Adjustments and Monitoring

• The formula provides only a starting point—adjust fluid rates based on clinical response, not rigid adherence to calculated volumes 4
• Titrate fluids hourly based on urine output, avoiding both under-resuscitation (burn shock) and over-resuscitation ("fluid creep") 1, 2

Special Circumstances Requiring Higher Volumes

• Inhalation injury: Significantly increases fluid requirements 3, 4
• Electrical burns: Deeper tissue damage requires higher volumes and monitoring for myoglobinuria 3
• Full thickness burns: May require volumes at higher end of range (4 mL/kg/% TBSA) 1
• Delayed resuscitation: Starting >2 hours post-burn may require increased volumes 3

Common Pitfalls to Avoid

• "Fluid creep": Over-resuscitation occurs in 76% of cases, averaging 6.3 mL/kg/% TBSA, leading to compartment syndrome, pulmonary edema, and intestinal edema 1, 5, 6
• Bolus administration for oliguria/hypotension: Accounts for 39% of excess fluid variance from Parkland estimates 7
• Inaccurate burn size assessment: Explains 9% of variance from expected volumes 7
• Using 0.9% NaCl: Avoid due to risk of hyperchloremic acidosis and acute kidney injury; use Lactated Ringer's instead 1

Real-World Application

• Studies show only 12-14% of patients actually receive volumes matching the Parkland formula, with most receiving 5.6-6.1 mL/kg/% TBSA 5, 4, 7
• Despite higher volumes than predicted, mortality remains acceptable (10-17%) when guided by urine output rather than formula adherence 4, 7
• The formula is a starting point, not a rigid target—clinical parameters (especially urine output) should guide ongoing adjustments 4