Parkland Formula for Burn Resuscitation
The Parkland formula calculates fluid requirements as 4 mL/kg/% total body surface area (TBSA) burned over the first 24 hours, with half administered in the first 8 hours and the remainder over the next 16 hours, using Ringer's Lactate or Hartmann's solution as the crystalloid of choice. 1, 2
Formula Calculation
The standard Parkland formula provides:
- Total 24-hour fluid volume = 4 mL × body weight (kg) × % TBSA burned 1, 2
- First 8 hours: Administer 50% of calculated volume 2, 3
- Next 16 hours: Administer remaining 50% of calculated volume 2, 3
The American Burn Association recommends a range of 2-4 mL/kg/%TBSA, though recent guidelines favor the modified approach using 3-4 mL/kg/%TBSA to reduce over-resuscitation risk 1, 2. A 2025 retrospective study demonstrated that using the modified Brooke's formula (3 mL/kg/%TBSA) resulted in significantly lower resuscitation volumes (3.37 vs 5.04 mL/kg/TBSA) with no difference in clinical outcomes compared to traditional Parkland 4.
Initial Bolus Administration
Before calculating the Parkland formula, administer 20 mL/kg of balanced crystalloid within the first hour regardless of burn size to address early hypovolemic shock. 5, 2, 3 This initial bolus is not adjusted for TBSA due to difficulties in accurate early assessment 5.
Fluid Type Selection
- First-line: Ringer's Lactate or Hartmann's solution 5, 2, 3
- Avoid: 0.9% Normal Saline due to hyperchloremic acidosis risk 2, 3
Indications for Formal Resuscitation
Adults: Burns ≥10% TBSA require formal fluid resuscitation 1, 2
Children: Burns ≥5-10% TBSA require formal fluid resuscitation 1, 2, 3
Special circumstances requiring resuscitation regardless of size: 1
- Burns involving face, hands, feet, or genitals
- Full-thickness burns
- Electrical burns
Pediatric Modifications
Children require higher fluid volumes due to increased surface area-to-weight ratio 5, 1:
- Modified Parkland for children: 3-4 mL/kg/%TBSA over 24 hours 5, 2, 3
- Add maintenance fluids using Holliday-Segar 4-2-1 rule for burns >10% TBSA 5, 2, 3
- Retrospective data shows children actually require approximately 6 mL/kg/%TBSA over 48 hours 5, 1, 2
Critical Monitoring and Titration
The Parkland formula provides only an initial estimate—actual infusion rates must be adjusted based on clinical response. 5
Primary endpoint: Urine output of 0.5-1 mL/kg/hour in adults and children 1, 2, 3
Secondary monitoring parameters: 5, 1
- Arterial lactate concentration
- Mean arterial pressure
- Advanced hemodynamic monitoring (echocardiography, cardiac output, central venous pressure) for persistent oliguria or instability
Electrical burns with myoglobinuria: Target higher urine output of 1-2 mL/kg/hour to prevent acute kidney injury 2
Major Pitfall: Fluid Creep
Over-resuscitation ("fluid creep") is a critical complication, with studies showing 76% of patients receive more than the upper Parkland limit, averaging 6.3 mL/kg/%TBSA. 2, 3 Both under-resuscitation and over-resuscitation increase morbidity and mortality 5, 1.
Complications of fluid creep include: 3
- Compartment syndrome
- Pulmonary edema
- Intestinal edema
- Abdominal compartment syndrome
Populations Requiring Higher Volumes
Certain patients may require volumes at the higher end (4 mL/kg/%TBSA) or above: 2
- Inhalation injury
- Full-thickness burns
- Electrical burns
- Delayed presentation (>2 hours post-injury)
A 2023 prospective multicenter study found that actual fluid received in the first 24 hours was at or above Parkland estimates, with albumin supplementation used when crystalloid rates exceeded targets 6.
Albumin Supplementation
For burns >30% TBSA, administer human albumin after the first 6 hours of management. 2 This reduces mortality and abdominal compartment syndrome (from 15.4% to 2.8%) 2. The 2023 ABRUPT trial confirmed that albumin is typically started when initial crystalloid rates exceed expected targets and improves fluid balance ratios 6.
Important Caveats
- No resuscitation formula has been rigorously validated or proven superior to others 5, 1
- Formulas developed for adults are not directly applicable to children 5
- The Rule of Tens is suitable only for prehospital care and has only in silico validation 5
- Time from injury is critical—early resuscitation (within 2 hours) reduces morbidity and mortality 5