Burn Area and Parkland Fluids: The Evidence Behind the Calculator

It is ten at night in the casualty. A 26-year-old woman weighing 50 kg has been brought in from a village near Shivamogga. Her sari caught fire at a kerosene stove four hours ago. The front of her trunk and her whole right arm are blistered and raw, and her face is red but not blistered. On the way, a nearby clinic gave her 500 mL of fluid. Your registrar asks you two questions: “How much of her is burnt, and how much fluid does she need?” This is an illustrative case, not a real patient.

By the end of this article you will be able to answer both, and to say why the answer to the second question changes every hour.

1. Counting the Burn Area

Only partial and full thickness burn is counted. Erythema alone is left out. Her red face is erythema, so it does not enter the sum.

“Why does that matter so much?” Because every percentage point goes into the formula as a multiplier. Counting erythema is a common reason for over-resuscitation. It is easy to see why it happens: a red face looks burnt. It is not part of the burn area.

In an adult, the rule of nines (Wallace, 1951) is quick. The front of the trunk is 18 and each upper limb is 9. So her burn is 18 plus 9, which is 27% of the total body surface area (TBSA). For a scattered burn, the palm method helps: ABA and ISBI count the patient’s palm with fingers as about 1%, and the national programme counts “one closed hand” as 1%.

The rule of nines is an adult chart. In a child the head is larger and the legs are smaller, and that is what the Lund and Browder chart (1944) corrects for. Here is the chart as the tool used to carry it, in one table. The figures are the percentage of the body surface for each region:

Read the head row from left to right. At birth the head is 19% of the body; in an adult it is 7%. So a scald to the head of an infant is a much larger burn than the same scald on an adult. The thighs and lower legs go the other way. The other regions do not change with age: neck 2, front and back of the trunk 13 each, each buttock 2.5, genitalia 1, each upper arm 4, each forearm 3, each hand 2.5 and each foot 3.5.

2. Which Formula?

Here the sources disagree, and you should know how. This is the table of starting volumes the tool used to carry as one:

The national programme (NPPMBI) gives Parkland, 4 mL/kg/%TBSA, for every patient. The American Burn Association’s ABLS 2018 starts adults at 2 and children under 14 at 3. ISBI 2016 gives a range of 2 to 4. All three use Ringer lactate, and all three give half in the first 8 hours from the burn and half over the next 16. The tool prints both volumes and leads with Parkland, because Parkland is the formula the national programme gives.

For our patient, Parkland gives 4 x 50 x 27, which is 5,400 mL in 24 hours. Half of it, 2,700 mL, is due in the first 8 hours. On the ABA starting figure of 2 mL/kg/%TBSA it would be 2,700 mL in 24 hours.

3. The Clock Starts at the Burn

“She reached us four hours late. Do the 8 hours start now?” No. The 8 hours run from the burn, not from arrival. In India many patients reach a burns unit hours after a flame or kerosene burn, so this is the usual case, not the rare one.

Under the national programme she is now behind the plan. Of the 2,700 mL due by the eighth hour, she has had 500 mL. That leaves 2,200 mL for the next four hours, which is 550 mL an hour, and the tool prints that rate. ABLS 2018, as reported by protocols built on it, does it differently: it starts at the formula’s hourly rate and advises against boluses to catch up. You will meet both ways on our wards, and it helps to know which one your unit follows.

4. The Urine Output Is the Target

The formula sets the first hour. The urine output, measured hourly through a catheter, sets every hour after that. Here are the targets the tool used to carry in one table:

For our patient of 50 kg, the national target of 0.5 to 1 mL/kg/h is 25 to 50 mL an hour. If she makes 15 mL, the rate goes up; if she makes 90 mL, it comes down. The formula number is not a promise. It is where you start.

“What happens if we simply give the whole formula and walk away?” Patients often receive far more than the formula predicts. This is called fluid creep. The excess brings abdominal and limb compartment syndrome, pulmonary oedema and conversion of partial to full thickness burn (Saffle 2016). None of the sources caps the %TBSA used in the formula, so a very large burn gives a very large volume. The hourly urine output is what keeps it honest.

5. Children Are Not Small Adults

Burns in children are common in India. The tool’s Indian source put it this way (Sharma and Parashar 2010):

Children make up 17 to 25% of burn admissions in India. Scalds cause most burns below three years.

Two things change for a child. First, the area: use the Lund and Browder chart, not the rule of nines. Second, the sugar. A small child has small glycogen stores, so a child under 30 kg receives maintenance fluid with 5% dextrose on top of the resuscitation fluid (ABLS), and the blood glucose is checked. Maintenance is Holliday and Segar: 100 mL/kg/day for the first 10 kg, 50 for the next 10, and 20 above 20 kg.

6. Electrical Burns, Chemical Burns and Referral

• High-voltage electrical: the skin burn understates the muscle injury. Watch the heart, the creatine kinase, the urine for pigment and the limbs for compartment syndrome. With pigment in the urine, the target is higher, as the table above shows.
• Chemical: irrigate with copious water first. The national programme lists every chemical burn as critical.
• Inhalation injury raises the fluid need above the formula and threatens the airway within hours.

Our patient, at 27% in an adult, is above the national programme’s critical burn threshold of 25%, so she belongs in a burns unit. The tool prints the referral criteria of all three sources.

Back to Our Patient

Her burn is 27%, with the red face left out. Parkland gives 5,400 mL of Ringer lactate in 24 hours, 2,700 mL by the eighth hour from the burn. She is four hours in and 2,200 mL behind, so the national programme’s rate is 550 mL an hour; a unit following ABLS would start at the formula’s hourly rate and not chase the deficit with boluses. Either way, a catheter goes in, and from the next hour her urine output, aimed at 25 to 50 mL an hour, decides the rate.

Try This

A 3-year-old boy of 12 kg has pulled a vessel of boiling water onto himself: a scald of 15% of his body surface, counted on the Lund and Browder chart. What does he need? Illustrative case.

Answer. He needs IV resuscitation: the national programme starts it above 10% in a child. Parkland gives 4 x 12 x 15, which is 720 mL of Ringer lactate in 24 hours, 360 mL of it in the first 8 hours from the burn. Because he weighs under 30 kg, he also gets maintenance with 5% dextrose: 100 mL/kg/day for his first 10 kg and 50 for the next 2, which is 1,100 mL a day. Check his blood glucose, and aim his urine output at 1 to 1.5 mL/kg/h, which is 12 to 18 mL an hour.

Take-Home Points

• Count only partial and full thickness burn; leave erythema out.
• Use the Lund and Browder chart in children: a child’s head is a bigger share of the body.
• The 8 hours run from the burn, not from arrival.
• The formula sets the first hour; the hourly urine output sets every hour after it.
• A child under 30 kg gets maintenance with 5% dextrose on top, and a glucose check.

For maintenance fluids and the Holliday and Segar figures, see Maintenance IV Fluids and Calories: The Evidence Behind the Calculator; for tetanus cover, Tetanus Prophylaxis After a Wound: The Evidence Behind the Pathway.

Declaration: the author built and maintains the tool. It is free to use, and is still in administrator preview, pending clinical review. The figures in this article are those the tool carried in its Evidence tab on 5 November 2026, each from the source the tool names. The illustrative cases follow the tool’s rules; check the tool’s result for a real patient.

References

1. Baxter CR, Shires T. Physiological response to crystalloid resuscitation of severe burns. Ann N Y Acad Sci. 1968;150(3):874-94.
2. Baxter CR. Fluid volume and electrolyte changes of the early postburn period. Clin Plast Surg. 1974;1(4):693-703.
3. Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol Obstet. 1944;79:352-8.
4. Wallace AB. The exposure treatment of burns. Lancet. 1951;1(6653):501-4.
5. American Burn Association. Advanced Burn Life Support Course: Provider Manual, 2018 Update. Chicago: American Burn Association; 2018.
6. Cartotto R, Johnson LS, Savetamal A, Greenhalgh D, Kubasiak JC, Pham TN, et al. American Burn Association clinical practice guidelines on burn shock resuscitation. J Burn Care Res. 2024;45(3):565-89.
7. ISBI Practice Guidelines Committee. ISBI Practice Guidelines for Burn Care. Burns. 2016;42(5):953-1021.
8. Directorate General of Health Services, Ministry of Health and Family Welfare. National Programme for Prevention and Management of Burn Injuries (NPPMBI): Standard Treatment Guidelines for Burns. New Delhi: Government of India; [date not stated].
9. Sharma RK, Parashar A. Special considerations in paediatric burn patients. Indian J Plast Surg. 2010;43(Suppl):S43-50.
10. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823-32.
11. Saffle JR. Fluid creep and over-resuscitation. Crit Care Clin. 2016;32(4):587-98.