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

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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!

References

1. Chung KK, Wolf SE, Cancio LC, Alvarado R, Jones JA, McCorcle J, King BT, Barillo DJ, Renz EM, Blackbourne LH. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009 Aug;67(2):231-7. Pubmed.
2. Chung KK, Salinas J, Renz EM, Alvarado RA, King BT, Barillo DJ, Cancio LC, Wolf SE, Blackbourne LH. Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10. J Trauma. 2010 Jul;69 Suppl 1:S49-54. Pubmed .
3. Dr. Cliff Reid's Resus.Me post on Burns and Resuscitation (Oct 19, 2009) 
4. Saffle JI. The phenomenon of "fluid creep" in acute burn resuscitation. J Burn Care Res. 2007 May-Jun;28(3):382-95. Pubmed

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