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com
Original article
1
Department of Anaesthetics,
Cardiff & Vale University Local
Health Board, Cardiff, UK
2
School of Medicine, Swansea
University, Swansea, UK
3
Department of Anaesthetics,
Welsh Centre for Burns, ABM
University Local Health Board,
Swansea, UK
Correspondence to
Dr Abrie Theron, Department
of Anaesthetics, Cardiff & Vale
University Local Health Board,
Cardiff CF14 4XW, UK;
drabrietheron@yahoo.co.uk
Received 26 March 2013
Revised 28 May 2013
Accepted 1 June 2013
Published Online First
22 June 2013
To cite: Theron A,
Bodger O, Williams D.
Emerg Med J 2014;31:
730–735.
730
Comparison of three techniques using the Parkland
Formula to aid fluid resuscitation in adult burns
Abrie Theron,1 Owen Bodger,2 David Williams3
ABSTRACT
We performed a randomised study to compare the
accuracy and speed of three different techniques ( pen
and paper, electronic calculator and a novel graphic
device: ‘nomogram’) for calculation of resuscitation fluid
requirements for adults in the first 24 h of burn injury,
based on the Parkland Formula. We also assessed
acceptability of each technique using visual analogue
scores and qualitative analysis of free text responses. 28
participants performed 252 calculations using a series of
computer generated simulated patient data. For
nomogram, electronic calculator, pen and paper:
Magnitude of error [low (≥25%), medium (≥50%), high
(≥75%)]: [6.0%, 1.2%, 0%], [17.9%, 14.3%, 8.3%],
[25%, 16.7%, 9.5%]; p<0.002. Calculation time: [sec:
mean (SD)]: 94(34), 73(31), 214(103); p<0.001. The
mean (SD) of the difficulty scores for each method were
23(17), 17(14) and 70(21) out of 100. Of the 28
participants 15 preferred the calculator, 12 preferred the
nomogram and 1 scored the calculator and nomogram
equally (table 3). The nomogram was significantly more
accurate at all levels, almost as fast as an electronic
calculator, and deemed easy to use. It is low cost and
robust, and provides a rapid means of detecting and
preventing the large errors that we have shown can
occur when an electronic device is used as the only
method of calculation. We therefore suggest that the
Parkland Formula nomogram is a suitable method for
calculation of resuscitation fluid requirements in adult
burns. Fluid requirement should, however, be reviewed
frequently, and adjusted to ensure adequate organ
perfusion.
BACKGROUND
Inadequate fluid resuscitation of acute burns may
result in hypovolaemic shock and inadequate perfu-
sion of vital organs resulting in single to multiorgan
failure and Systemic Inflammatory Response
Syndrome (SIRS).1 Excessive fluid resuscitation
may result in fluid overload causing myocardial
infarction, abdominal compartment syndrome and
burn depth conversion with increased requirement
for escharotomies, fasciotomies and grafts.2
The original Parkland Formula is the most
widely used formula worldwide to guide early fluid
resuscitation in burns.3 It is a good starting point;
however, fluid administration should ultimately be
titrated to clinical signs of adequate organ perfu-
sion, as inferred from urine output of 0.5–1.0 mL/
kg/h and mean arterial blood pressure (MABP) of
around 70 mm Hg.1 2 4–7
Most mathematical relationships, including burns
fluid resuscitation formulae, can be expressed in
algebraic or graphic form; and the two forms can be
interconverted using analytic geometry. Nomograms
Theron A, et al. Emerg Med J 2014;31:730–735. doi:10.1136/emermed-2013-202652
(or nomographs) are one such form of graphical
representation, in which the user typically aligns a
straight edge (‘isopleth’) between two graduated
scales at points corresponding to the values of the
input variables, and reads the value of the output
variable where the isopleth intersects a third scale.8
Prior to the introduction of electronic calculators
and computers, nomograms were widely used to
rapidly solve specific mathematical equations in
engineering and in medicine, and are still routinely
used in safety-critical industries, such as aviation,
to cross-check results calculated by electronic
means.9 10 In the field of burns management, nomo-
grams have been designed to calculate burn surface
area and estimate carbon monoxide exposure.11 12
Williams has designed a compound parallel scale
alignment nomogram (figure 1) based on the
Parkland Formula for the calculation of fluid
requirement in adults during the first 24 h postburn
injury.13 Standard algebraic methods were used for
construction, aided by a spreadsheet (Excel,
Microsoft, Redmond, Washington), and graphics
software (Rhinoceros3D, McNeel North America,
Seattle, Washington; Illustrator, Adobe Systems, San
Jose, California).14 The method of use is shown in
figure 2.
METHOD
The study was a randomised volunteer study to
compare accuracy and response time for calculation
of resuscitation fluids from the Parkland Formula
using calculator, pen and paper and nomogram
methods. The null hypothesis was that ‘there is no
difference in accuracy or speed of calculation when
comparing the three methods’. The study was anon-
ymised and non-clinical, therefore, no formal ethics
or research committee approval was required.
Appropriate letters of exemption were obtained
from our Trust’s research coordinator and ethics
committee.
Power analysis was informed by a review of a
comparable study;15 and a pilot study in which 11
participants performed 99 calculations using all
three techniques. Moderate errors (≥50%)
occurred in 12.1% and 0.0% of calculations with
the calculator and nomogram, respectively. For a
superiority test with 90% power and 5% error rate,
this suggested a sample size of 76 calculations for
each of the three techniques.
If each participant performed too few calcula-
tions, the data would not be representative; but too
many calculations could result in declining per-
formance due to fatigue. We therefore decided an
acceptable compromise would be a total of nine
calculations per participant—that is, three using
each of the 3 methods.
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Figure 1 The improved Parkland Formula nomogram for adult burns (after:13).
The 28 participants (12 of whom were consultants) included
22 anaesthetists, 5 plastic surgeons and one band 6 nurse. Only
three participants had no prior experience of using the Parkland
Formula. Following full explanation and informed consent, par-
ticipants signed a consent form and completed an anonymised
demographic data collection form which recorded their age,
gender, job title and prior experience in using the Parkland
Formula.
All subjects then received instruction on how to use the
Parkland Formula, how to calculate the Volume To Be Infused
(VTBI) per period (mL) and the appropriate rate of administra-
tion of resuscitation fluids per period (mL/h), using each of the
three methods. It was emphasised that the time of the first (8 h)
period of resuscitation commenced from the time of the burn
injury, not from the time of arrival at the receiving hospital, and
participants were shown how to adjust the calculations in each
case to compensate for this.
Many participants were not familiar with the use of the iso-
pleth, and logarithmic scales used on the nomogram and the
method of reading and interpolating values was explained.
Participants had unlimited opportunity to practice each method
and did not proceed until they felt confident to perform the cal-
culations with all three methods.
Participants were instructed to perform the calculations as
quickly as possible to a level of ‘clinically acceptable’ accuracy;
however, it was emphasised that accuracy was more important
Theron A, et al. Emerg Med J 2014;31:730–735. doi:10.1136/emermed-2013-202652
Original article
than speed of calculation. During the study, participants were
allowed to refer to printed copies of the Parkland Formula, its
method of use and instructions for the use of the nomogram.
Bespoke software was developed for this study using Python,
an open-source, cross-platform, object-oriented, programming
language, particularly suited to scientific applications.16 The
software created a total of nine scenarios for each participant
with three scenarios for each of the three calculation techniques.
The software randomly assigned the sequence that dictated the
calculation technique to be used for each scenario. For each
simulated scenario, the software randomly generated a new set
of integer values within appropriate ranges for BWt (40–
150 kg), Total Burn Surface Area (TBSA) (10–100%) and Delay
(1–8 h), and calculated the correct answers for the fluid infusion
rates (mL/h) in each resuscitation period.
The software instructed the participant on which technique
to use for each scenario. Time was allowed for the participant
to prepare the appropriate equipment and printed materials to
perform the calculation. When the participant pressed the ‘start’
key, they were presented with the set of values from which to
calculate the correct fluid infusion rates in each period. At the
same time a software-based timer automatically started. When
the participant had entered all the fluid infusion rates, the timer
automatically stopped and the participant’s responses and
response time were stored. Participants were allowed to rest
between scenarios if necessary without incurring a time penalty.
731
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Original article
Figure 2 Example of how to use the Parkland Formula nomogram for adult burns.
When each scenario was completed, the software compiled all
data (including calculation technique used, values of all ran-
domly generated parameters, correct answers, participant’s
responses, and response times) and saved it to a spreadsheet for
subsequent analysis.
Participants then completed a post-test questionnaire. This
consisted of a series of continuous visual analogue scales (VAS,
graphic rating scales); where they were instructed to mark a
cross at the appropriate point on a line which ranged from ‘very
easy’ to ‘very difficult’ to describe their experience of ease of
use for each of the three techniques. There was also an optional
section for free text entry of written comments.
Information from the pre-test and post-test questionnaires
was transcribed onto a spreadsheet for subsequent analysis. Data
from the VAS were converted to continuous numerical data by
measuring the distance (mm) from the left hand side of the line
to the position of the cross marked by the participant, expressed
as a proportion of the total length of the line.
ANALYSIS
Statistical Package for the Social Sciences software, V.13 (SPSS,
Chicago, Illinois) was used to aid analysis of data.
The Parkland Formula requires several measurements as
input, each of which must be estimated. The expected errors for
each of these variables are not trivial (table 1). Combining these
using the sum of squared fractional errors gives an expected
error of around 28% in the final answer.17 Given that this is the
size of error that is likely to occur irrespective of the quality of
the calculation, then it must represent the lower end of clinical
732
significance. We therefore defined three thresholds of error—25,
50 and 75%—representing categories of low, medium and high
clinical significance as a proportion of the correct solution. The
accuracy of each method was calculated across all three thresh-
olds using a non-parametric test (χ2 test of association).
The data for response times was skewed; however, a log trans-
form of this data was accepted by the Kolmogorov–Smirnov
goodness-of-fit test (p=0.433) and, therefore, a parametric test
analysis of variance (ANOVA) was appropriate. Demographic data
were mainly categorical and were therefore analysed using either
ANOVA or a two-way χ2 test. The VAS scores comprised too small
a sample (only 28 unique cases) to allow reliable assessment of dis-
tribution, and so non-parametric methods were used for analysis.
Table 1 Common sources of potential error associated with the
Parkland Formula
Variable Potential error (±) (%)
Estimation of body weight 10
Estimation of TBSA 20,7
Variation in Volume To Be Infused (VTBI) depending 14 (ie, 3.5±0.5 mL/
on which version of Parkland Formula is used: h=0.5/3.5=14%)
VTBI=4 mL/BWt(kg)/%TBSA or
VTBI=3 mL/BWt(kg)/%TBSA
Estimation of the time elapsed between the time of 10
burn injury and the start of fluid resuscitation
TBSA, total burn surface area.
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Original article

association demonstrated significant differences between the

Table 2 Likelihood ratio test results
accuracy of the three methods for all thresholds, with p values
Comparison 25% error 50% error 75% error of 0.003, 0.002 and 0.018 for 25, 50 and 75% errors (table 2).
The calculator performed no better than pen and paper for any
Calculator vs nomogram 0.017* 0.001** 0.007**
of the thresholds, and the nomogram was superior to both these
Calculator vs pen & paper 0.259 0.670 0.787
techniques.
Nomogram vs pen & paper 0.001** <0.001*** 0.004**
The response time for each of the three methods of calcula-
Overall 0.003** 0.002** 0.018*
tion was significantly different from the other two ( posthoc
*=p<0.05, **=p<0.01, ***=p<0.001. ANOVA: p<0.001). The calculator was the fastest method, fol-
lowed by the nomogram, and then pen and paper, with mean
times (SD) of 73 (31), 94 (34) and 214 (103) seconds, respect-
The free text comments from the post-test questionnaire were ively. There was considerable overlap between the response
analysed using an iterative constant comparison (‘grounded’) times for the nomogram and calculator, although only two indi-
approach to allow identification and classification of emerging vidual subjects were able to use the nomogram faster than the
themes.18 Specific comments which illustrated a particular point calculator (figure 3).
of view, or that were representative of common themes, were All three methods showed evidence of improvement of
quoted verbatim in anonymised form. response time with repetition—that is, a learning effect. This
was strongest for the nomogram, reflecting its novelty
RESULTS (p<0.001, p<0.001 and p=0.001 for calculator, nomogram
Only around 84% of all calculations were free from error; and pen and paper, respectively). Between the first and third
defined as at least 25% of proportion of the correct answer. attempts, the mean additional time required to use the nomo-
Errors occurred during calculation of both the rate for the first gram compared with the calculator fell from 27 s (or 29%) to
and the second period for all methods, however, the number of 14 s (23%) (figure 4).
errors was not large enough to demonstrate any significant rela- The VAS scores showed that some participants had a strong
tionship between the method used (calculator, nomogram, pen preference for the nomogram, while others strongly preferred
and paper) and the stage of calculation (rate for first and second the calculator. The calculator was generally considered easier to
period) during which the errors occurred. use, but the difference was not statistically significant under a
The best performing technique at each level was the nomo- Wilcoxon-signed rank test. No participant reported finding
gram, making errors of low significance (≥25%), medium sig- these two methods very difficult. The mean (SD) of the diffi-
nificance (≥50%), and high significance (≥75%), respectively, culty scores for each method were 17% (14), 23% (17) and
6.0, 1.2 and 0% of the time, compared with 17.9, 14.3 and 70% (21) for calculator, nomogram and pen and paper techni-
8.3% for the calculator, and 25, 16.7 and 9.5% for the pen and ques, respectively (table 3). Of the 28 participants, 15 preferred
paper technique. A comparison of the frequency of occurrence the calculator, 12 preferred the nomogram and 1 scored calcula-
of errors with the three different methods using the χ2 test of tor and nomogram equally. Univariate statistical analysis showed

Figure 3 Histogram of response times for calculator, nomogram and pen and paper techniques.

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Original article

individuals and ambient lighting conditions. A further advantage

of the monochrome chart is that it may be readily photocopied.
Concerns included that the nomogram was ‘not particularly
intuitive’ (1), and that scale markings could be obscured by an
opaque isopleth (1). A transparent straight edge was used, but
the problem persisted due to refraction; therefore, a transparent
polycarbonate isopleth with a central hairline graticule was con-
structed which we will use in future studies.

DISCUSSION
The software developed for this study worked efficiently with
no problems. The randomisation prevented bias due to learning
effects or fatigue. The use of automated timing eliminated any
potential observer error. Both participants and investigators
were blinded to the correct results of the calculations and
response time to prevent bias. The nomogram was designed
using the original Parkland Formula which is based on a VTBI
of 4 mL/BWt(kg)/TBSA (%); however, it would be an easy
matter to redraft this as necessary to incorporate a new or
Figure 4 Plots of mean response time against attempt for each of amended formula.
the three methods of calculation.
Various systems have been designed to aid calculation of
resuscitation fluid requirements based on the Parkland Formula
no significant correlation between any of the demographic vari- including: dedicated electronic devices,19 computer software,20
ables studied and any of the outcome measures (accuracy, speed, tables21 and mechanical calculators.22 Compared with these,
user preference). nomograms are low cost, durable (if printed on plastic slates or
Twenty-five of the 28 participants submitted free text responses, waterproof paper), maintenance-free and have no moving parts.
with each response containing 1–3 discrete items. Qualitative ana- Nomograms may be printed on paper with a copy of the Lund
lysis identified three main themes (in italics), with representative and Browder chart on the reverse,23 and filed in patient notes to
comments and number of responses in parentheses. provide a permanent record of the calculation.
Acceptability: Many respondents (10) remarked that the In contrast with the nomogram, many of the above systems
nomogram was easy to use. Some (2) felt that it was easier to are unable to correct the calculation for the time of burn and
use than a calculator, particularly ‘in a resuscitation situation’. for preadmission fluids, and give the result as a total volume of
Three participants noted that the nomogram soon became fluid per resuscitation period (mL) rather than a rate of infusion
quicker and easier to use after a little practice. No participants (mL/h). They are, therefore, of limited use in practice.
expressed any difficulties interpreting and interpolating the loga- Nomograms are easy to read and provide continuous values
rithmic scales. across the entire range: tables may be difficult to read and the
Suggestions for improvement included omission of the scale discrete values can introduce rounding errors. The use of loga-
showing infusion rate in giving set drops per minute as it could rithmic scales ensures that the accuracy of the nomogram is
potentially be confused with the infusion rate in mL/h (2), greater at the more clinically significant lower range.
improving legibility by using a larger format (4), different scale Electronic calculators and computers may not be readily avail-
graduations (3) and colour coding (1). We incorporated a ‘drops able and require a reliable electrical power supply. By nature of
per minute’ scale for infusion rate because we anticipate use of its design, the nomogram is an approximate method of calcula-
the nomogram where volumetric infusion devices may not be tion compared with electronic devices, however, the nomogram
readily available. Omitting this scale may aid clarity. Larger incorporates the Parkland Formula into its design and constrains
formats offer marginal gains in accuracy at the expense of port- both the input variables and output to a clinically relevant range
ability. In practice, the degree of accuracy from the A4 format of values, and is therefore incapable of producing the
was found to be adequate for clinical purposes. Colour coding unbounded errors that arise due to misapplication of the
is attractive; however, colour perception varies between formula or unrecognised keystroke errors on data entry which
have been shown to occur in 4% of key presses.24
The importance of cross-checking dosage calculations of
drugs and fluids by two individuals using two different methods
Table 3 Summary of results has been recently emphasised.25 Safety-critical calculations in
the aviation and diving industries are routinely verified using
Magnitude of error Difficulty both electronic and graphic techniques.10 If an electronic device
Calculation scores
Low % Medium % High % time (mean (mean is used as the primary method of calculation for resuscitation
Method (≥25%) (≥50%) (≥75%) (SD)) (SD)) (%) fluids in acute burn injuries, the nomogram can be used to
rapidly cross-check the calculation and prevent patients coming
Nomogram 6.0 1.2 0 94 (34) 23 (17) to harm due to the effects of overtransfusion or undertransfu-
Calculator 17.9 14.3 8.3 73 (31) 17 (14) sion. The nomogram gives a clear visual expression of the rela-
Pen & 25 16.7 9.5 214 (103) 70 (21) tionships between the variables. It is simple to confirm correct
Paper
entry of data by performing the calculation in reverse graphic-
p=0.003 p=0.002 p=0.018 p<0.001
ally. This would be difficult to do algebraically or using the
systems described above.

734 Theron A, et al. Emerg Med J 2014;31:730–735. doi:10.1136/emermed-2013-202652

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CONCLUSIONS
The nomogram method for calculation of adult fluid resuscita-
tion requirements by the Parkland Formula was more accurate
and faster than pen and paper calculations. By comparison with
an electronic calculator, the nomogram resulted in fewer and
less extreme errors, was only slightly slower, and did not
present the disadvantages associated with electronic devices as
described above. The majority of participants found the nomo-
gram intuitive, easy to use and accuracy and speed further
improved with practice.
We therefore propose that with appropriate instruction, the
nomogram is a suitable means of calculating initial resuscitation
fluid requirements in adult burns. Ultimately, fluid resuscitation
should be titrated to the patient’s clinical response, aiming for
adequate organ and tissue perfusion, as inferred from urine
output and other physiological parameters (eg, MABP). As a
primary means of calculation the nomogram would be particu-
larly useful for clinicians with limited experience of burns (eg, in
a district general hospital and emergency department) or for
those working in difficult environments, or developing countries.
If an electronic device is used as the primary means of calcula-
tion, the nomogram offers a rapid means of checking for errors.
Contributors DW developed the nomograms, graticule and software. AT collected
the data. OB performed the power calculations and statistical analysis and
presentation of data. All three authors designed the study and contributed to the
writing and review of this article.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1 Holm C. Resuscitation in shock associated with burns. Tradition or evidence-based
medicine? (review). Resuscitation 2000;44:157–64.
2 Sjöberg F. The ‘Parkland protocol’ for early fluid resuscitation of burns: too little,
too much or…even…too late…? Acta Anesthesiol Scand 2008;52:752–6.
3 Baxter C, Shires T. Physiological response to crystalloid resuscitation of severe burns.
Annals of the N Y Acad Sci 1968;150:874–94.
Theron A, et al. Emerg Med J 2014;31:730–735. doi:10.1136/emermed-2013-202652
Original article
4 Mitra B, Fitzgerald M, Cameron P, et al. Fluid resuscitation in major burns. ANZ J
Surg 2006;76:35–8.
5 Fodor L, Fodor A, Ramon Y, et al. Controversies in fluid resuscitation for burn
management: literature review and our experience. Injury 2006;37:374–9.
6 Berger M, Bernath M-A, Chiolero R. Resuscitation, anaesthesia and analgesia of the
burned patient. Curr Opin Anaesthesiol 2001;14:431–5.
7 Collis N, Smith G, Fenton O. Accuracy of burn size estimation and subsequent fluid
resuscitation prior to arrival at the Yorkshire Regional Burns Unit. A three year
retrospective study. Burns 1999;25:345–51.
8 d’Ocagne M. Traite de Nomographie. 1st ed. Paris: Gauthier-Villars, 1899.
9 Boothby W, Sandiford R. Nomographic charts for the calculation of the metabolic
rate by the Gasometer method. Boston Med and Surg J 1921;185:337–54.
10 Australian Transport Safety Bureau. Aviation Research & Analysis Report AR-2009–
052: Take-off Performance Calculation and Entry Errors: A Global Perspective In:
Australian Government, editor: ATSB, 2009.
11 Clark C, Campbell D, Reid W. Blood carboxyhaemoglobin levels in fire survivors.
Lancet 1981;i:1332.
12 Malic C, Karoo R, Austin O, et al. Resuscitation burns card—a useful tool for burn
injury assessment. Burns 2007;33:195–9.
13 Williams D. Nomograms to aid fluid resuscitation in acute burns. Burns
2011;37:543–5.
14 Hoelscher R, Arnold J, Pierce S. Alignment charts. Graphic aids in engineering
computation. 1st ed. New York: McGraw Hill, 1952:62–117.
15 Lindford A, Lim P, Klass B, et al. Resuscitation tables: a useful tool in calculating
pre-burns unit fluid requirements. Emerg Med J 2009;26:245–9.
16 Langtangen H, ed. A primer on scientific programming with Python. London:
Springer, 2009.
17 Taylor J. An introduction to error analysis: the study of uncertainties in physical
measurements. Herndon, VA: University Science, 1982.
18 Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for
developing grounded theory. 3rd ed. Thousand Oaks, CA: Sage, 2008.
19 Dingley J, Williams D. A hand-held electronic device to calculate fluid requirements
for burns. Eur J Anaesthesiol 2010;27:192–3.
20 Milner S, Smith C. Palm-top computer application for fluid resuscitation in burns.
Plastic and Reconstructive Surgery 2001;108:1838–9.
21 de Mello W, Greenwood N. The burns fluid grid. A pre-hospital guide to fluid
resuscitation in burns. J R Army Med Corps 2009;155:27–9.
22 Jenkinson L. Fluid replacement in burns: a burns calculator. Ann R Coll Surg Eng
1982;64:336–8.
23 Lund C, Browder N. The estimation of areas of burns. Surg Gynecol Obstet
1944;79:352–8.
24 Number entry interfaces and their effects on errors and number perception. IFIP
Conference on Human-Computer Interaction, Interact 2011, 2011.
25 Institute for Safe Medication Practices. Fluorouacil incident root cause analysis.
Canada: ISMP, 2007.
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Comparison of three techniques using the

Parkland Formula to aid fluid resuscitation
in adult burns
Abrie Theron, Owen Bodger and David Williams

Emerg Med J 2014 31: 730-735 originally published online June 22,
2013
doi: 10.1136/emermed-2013-202652

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