Trick of Trade: Rule of 10’s for burn fluid resuscitation

Michelle Lin, MD on

 

A patient presents with burns to both his arms, chest, and abdomen (anteriorly only) from a flash fire. That’s about 27% total body surface area (TBSA). So how much IV fluid should be given?

Be aware of a phenomenon known as “fluid creep”, where patients actually get WAY too much IV fluids than they should, which can cause delayed complications such as ACS, pulmonary edema, and compartment syndrome. Don’t forget that patients often get a lot of IV fluids in the prehospital setting, which should also be factored in.

 

A patient presents with burns to both his arms, chest, and abdomen (anteriorly only) from a flash fire. That’s about 27% total body surface area (TBSA). So how much IV fluid should be given?

Be aware of a phenomenon known as “fluid creep”, where patients actually get WAY too much IV fluids than they should, which can cause delayed complications such as ACS, pulmonary edema, and compartment syndrome. Don’t forget that patients often get a lot of IV fluids in the prehospital setting, which should also be factored in.

Two formulas are available to help guide fluid resuscitation. Using the Parkland versus modified Brooke formula have no clinical difference in outcome. 1

Parkland formula

  • Fluid requirements = TBSA burned (%) x Wt (kg) x 4 mL
  • Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours.

Modified Brooke formula

  • Fluid requirements = TBSA burned (%) x Wt (kg) x 2 mL
  • Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours.
Quick, at what rate should you order your IV fluids for your patient with 27% TBSA scald burns? It’s challenging to pull out your favorite medical calculator during the middle of your resuscitation. You should delegate this task to a team member. In the meantime …

Trick of the Trade

Use the rule of 10’s to start

  1. Estimate burn size to the nearest 10%.
  2. Multiply %TBSAx10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg).
  3. For every 10 kg above 80 kg, increase the rate by 100 mL/hr.

So let’s say we had patients of different weights with 27% burns, the calculated rates (mL/hr) for each of the approaches are:

Weight (kg) Mod Brooke Parkland Rule of 10’s
30 101 203 n/a
40 135 270 300
50 169 338 300
60 203 405 300
70 236 473 300
80 270 540 300
90 304 608 400
100 338 675 500

 

Note that the initial resuscitation rate with the rule of 10’s falls typically between the modified Brooke and Parkland formula values. This helps you avoid “fluid creep”.

Thanks to Dr. Natalie DeSouza (UCSF-SFGH EM resident) for this tip!

Additional Reading
  1. Dr. Cliff Reid’s Resus.Me post on Burns and Resuscitation (Oct 19, 2009)
1.
Chung K, Wolf S, Cancio L, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-7; discussion 237. [PubMed]

Author information

Michelle Lin, MD

Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco

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Tags: Trauma Tricks of the Trade

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