Burn fluid resuscitation

Parkland came out of Parkland Memorial Hospital in Dallas, from Baxter and Shires in 1968: 4 mL per kilogram per percent TBSA of lactated Ringer’s, half of it in the first eight hours. It became the thing everybody learned, and for most of fifty years that was fine.

What broke it was that patients kept receiving far more than the formula predicted. Basil Pruitt named the problem “fluid creep” in 2000, and a 2007 review by Saffle tied the excess to oedema in unburned tissue building after the first eight hours, and to abdominal compartment syndrome. Over-resuscitation stopped being a nuisance and started being counted as a cause of death.

So the American Burn Association halved the starting point. It did that in 2011, in the ABLS Course Manual, and in 2024 wrote it into a formal guideline: “We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes.” That figure is the Modified Brooke formula, published by Pruitt at the US Army Institute of Surgical Research in 1979, so the “new” number is older than most of the people using it.

Two limits on that guideline are worth knowing before you quote it. It covers adults with burns of 20% TBSA or more, in the first 48 hours. It does not cover children, and it does not cover smaller burns. And it is explicit that 2 mL is the opening rate only: “this recommendation suggests only the initial fluid rate, and that titration based on the patient’s response must follow.”

Both formulas multiply by %TBSA, so an error there is multiplied straight into the volume. Two things about that estimate matter more than which coefficient you picked.

Superficial burns do not count. Only partial and full thickness go into the number, and a sunburn-red back added to the total is a large volume of fluid nobody needed.

And the Rule of Nines is an adult rule. A child’s head is a far larger share of their body: the commonly taught paediatric figures are 18% for the head and 13.5% for each leg, against 9% and 18% in an adult. Sources do not fully agree on the paediatric numbers, which is itself a reason to reach for a Lund and Browder chart in a child rather than a rule of thumb.

• 2 mL/kg/%TBSA, the initial rate, and the 20% adult scope: Cartotto R et al., “American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation”, Journal of Burn Care & Research 45(3):565-589, 2024. The same guideline is the source for the 2011 ABLS change, the Ivy Index at 250 mL/kg, and the 0.5 mL/kg/hr adult urine target.
• Parkland, 4 mL/kg/%TBSA and the 8/16 hour split: Baxter CR, Shires T, “Physiological response to crystalloid resuscitation of severe burns”, Annals of the New York Academy of Sciences 150(3):874-894, 1968.
• Modified Brooke, 2 mL/kg/%TBSA: Pruitt BA, US Army Institute of Surgical Research, 1979. Distinct from the original 1953 Brooke formula, which included colloid.
• Fluid creep: named by Pruitt BA, Journal of Trauma49(3):567-568, 2000; reviewed by Saffle JR, “The phenomenon of ‘fluid creep’ in acute burn resuscitation”, 2007.
• Ivy Index: Ivy ME et al., Journal of Trauma 49:387-391, 2000, where 250 mL/kg is the trigger to begin measuring bladder pressure rather than a ceiling.
• Paediatric urine target and the 30 kg split: Romanowski KS, Palmieri TL, “Pediatric burn resuscitation”, 2017. The International Society for Burn Injuries guideline (2016) sets a lower adult target of 0.3 to 0.5 mL/kg/hr, which disagrees with the familiar 0.5 to 1.0 band.

Checked 24 August 2026. Where sources disagree, the disagreement is stated rather than resolved: the ABLS provider manual itself is paywalled and has not been read directly, and it is the document an Alberta clinician would actually be taught from.