Parkland formula paediatrics

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Parkland formula burns fluid resuscitation pediatric

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burns fluid resuscitation pediatric

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Parkland Formula in Paediatrics

The Basic Formula

The modified Parkland (Baxter) formula is:

4 mL x weight (kg) x % TBSA burned = total volume (mL) of Lactated Ringer's over 24 hours

First half given in the first 8 hours (from time of burn, not time of arrival)
Second half given over the next 16 hours

Intravenous resuscitation is indicated in children with burns >10% TBSA (vs. >15% in adults).

Key Paediatric Difference: Maintenance Fluids

Unlike adults, children must receive maintenance fluids in addition to the resuscitation volume. This is because:

Children have a larger surface area to body mass ratio, leading to greater insensible fluid losses
Their immature kidneys need higher fluid volumes for adequate resuscitation
Omitting maintenance can cause dangerous hypoglycaemia

Maintenance is calculated using the Holliday-Segar method, typically given as dextrose-saline:

Weight band	Maintenance rate
First 10 kg	100 mL/kg/24 h
Next 10 kg (10-20 kg)	50 mL/kg/24 h
Each kg >20 kg	20 mL/kg/24 h

Bailey and Love's Short Practice of Surgery, 28th Ed.

Limitation of Parkland Formula in Children

Sabiston's Textbook of Surgery notes that the standard adult Parkland formula tends to underresuscitate children with minor burns and overresuscitate large burns because it does not account for TBSA variability as the paediatric patient develops. Two paediatric-specific formulas are preferred in specialist burn centres:

Paediatric-Specific Formulas

Cincinnati Formula

Age group	Formula
Young children	4 mL/kg/% TBSA burn + 1500 mL/m² total BSA of LR. Half in first 8 h, half in next 16 h. First 8 h: add 50 mEq/L sodium bicarbonate. Third 8 h: add albumin (12.5 g of 25% albumin per litre). Give 5% dextrose as needed.
Older children	4 mL/kg/% TBSA burn + 1500 mL/m² total BSA of LR. Half in first 8 h, remainder in 16 h. 5% dextrose as needed.

Galveston Formula (body surface area-based)

5000 mL/m² burn area + 2000 mL/m² total BSA of LR

Half in first 8 h, remainder in 16 h

Add 12.5 g of 25% albumin per litre of crystalloid

5% dextrose as needed

The Galveston formula uses BSA rather than weight, which better accounts for the changing TBSA-to-mass ratio in children.

Sabiston Textbook of Surgery, 21st Ed. (Table 42.4)

Rule of Nines: Paediatric Modification

The standard adult rule of nines does not apply to children. Because the head is proportionally larger and legs smaller in young children, the Lund and Browder chart should be used. Age-specific TBSA percentages must be applied (see Fig. 42.8 in Sabiston).

Monitoring

Fluid resuscitation is dynamic - rigid adherence to formulae is not appropriate. The primary monitor is urine output:

Weight	Target urine output
<30 kg	1 mL/kg/h
>30 kg	0.5 mL/kg/h

If urine output drops with signs of hypoperfusion (tachycardia, cool peripheries, raised lactate), give a bolus of 10 mL/kg. Avoid over-resuscitation, which leads to fluid creep, pulmonary oedema, and abdominal compartment syndrome.

Timing Note

Resuscitation starts from the time of burn, not time of arrival. Any prehospital delay must be accounted for when calculating the rate for the first 8-hour window.

Bailey and Love's Short Practice of Surgery, 28th Ed.
Sabiston Textbook of Surgery, 21st Ed.

Teach me ctev with images and mnemonics

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CTEV - Congenital Talipes Equinovarus (Clubfoot)

The Master Mnemonic: CAVE

Cavus - Adduction of forefoot - Varus of hindfoot - Equinus

This single word describes all 4 deformities of CTEV AND the order of correction in Ponseti casting.

What Exactly Is CTEV?

CTEV is a complex 3D deformity of the foot and ankle where the foot is:

Component	What it means	Visual cue
Cavus	High arch (plantar flexion of forefoot on hindfoot)	"Caved-in" arch
Adduction	Forefoot turned inward (medially)	Toes point in
Varus	Hindfoot inverted (heel turns in)	Sole faces up
Equinus	Plantarflexion at ankle (foot points down)	Like a horse hoof

The foot is small, stiff, and the sole faces inward/upward.

Skeletal Anatomy - Side by Side Comparison

Skeletal comparison of clubfoot vs normal vs related conditions (Miller's Review of Orthopaedics)

A - Clubfoot: varus hindfoot + adducted forefoot. B - Metatarsus adductus: normal hindfoot, adducted forefoot only. C - Normal foot. D - Skewfoot. E - Congenital vertical talus (rocker-bottom).

The key diagnostic differentiator: in CTEV both the hindfoot (varus) and forefoot (adduction) are abnormal. In metatarsus adductus, only the forefoot is adducted.

Radiographic Findings

Radiographic evaluation: normal foot vs clubfoot showing talocalcaneal parallelism (Miller's Review of Orthopaedics)

A - Normal foot: talus and calcaneus diverge (angle A normal = 20-40° on AP). B - Clubfoot: talus and calcaneus are PARALLEL (talocalcaneal angle <20°). The talus-1st metatarsal angle (B) is negative in clubfoot.

Radiographic Angles (Mnemonic: "Small angles, big problem")

View	Angle	Normal	Clubfoot
AP (Kite angle)	Talocalcaneal angle	20-40°	<20°
Lateral (Turco)	Talocalcaneal angle	~35°	<35°
AP	Talus-1st metatarsal angle	0-20°	Negative

The "parallelism" of talus and calcaneus on X-ray is the hallmark - they normally diverge like a V, but in CTEV they run parallel.

Note: X-rays are rarely used in infants due to minimal ossification - mainly used when diagnosis is unclear or in older patients.

Epidemiology

Mnemonic: "Boys get it Twice, Half get it on Both sides"

Incidence: ~1-2 per 1000 live births
Sex: Boys affected twice as often as girls (2:1 M:F)
Bilateral: 50% of cases are bilateral
Idiopathic: majority, though PITX1-TBX4 transcriptional pathway implicated

Aetiology - Mnemonic: "MAGIC"

Myelomeningocele - Arthrogryposis - Genetic (idiopathic) - Intrauterine positional - Chromosomal/syndromic

Category	Examples
Idiopathic (most common)	PITX1-TBX4 pathway; genetic predisposition
Neuromuscular	Myelomeningocele, spina bifida
Syndromic	Arthrogryposis, diastrophic dwarfism, prune-belly syndrome
Structural	Tibial hemimelia, Streeter dysplasia
Positional	Intrauterine compression (resolves spontaneously - ~10%)

90% of prenatally detected cases have structural defects needing treatment; 10% are positional and resolve on their own.

Pathoanatomy

The primary bony deformity is at the talus:

Talar neck has medial and plantar deviation
Calcaneus rotates medially
Navicular and cuboid displace medially

This drives contractures of:

Medial structures: tibialis posterior, flexor hallucis longus, flexor digitorum longus
Posterior structures: Achilles tendon
Fascial structures: plantar fascia, joint capsules, ligaments

Associated finding: absence or diminution of the anterior tibial artery (important for surgical planning - the posterior tibial artery must be protected during posteromedial release).

Severity Scoring

Two systems are used postnatally:

Pirani Score (0-6)

6 signs scored 0/0.5/1 each
Hindfoot score (3 signs): equinus, empty heel, posterior crease
Midfoot score (3 signs): medial crease, curved lateral border, talar head coverage
Higher score = more severe; predicts number of casts needed

Dimeglio Classification (0-20)

Grades equinus, varus, derotation, adduction
Grade I (benign) to Grade IV (very severe/teratologic)

Treatment

Primary Treatment: Ponseti Method (>90% success)

Mnemonic for correction order: CAVE (same as the deformities, corrected in this sequence)

Step	Correction	How
1. Cavus	First	Supinate forefoot, dorsiflex 1st ray
2. Adductus	Second	Lateral pressure on distal talar head as fulcrum
3. Varus	Simultaneous with adductus	Same lateral pressure manoeuvre
4. Equinus	Last	Gradual dorsiflexion after above corrected

Key rule: Never try to correct equinus before varus is corrected - this creates a rocker-bottom deformity.

The process:

Serial weekly manipulations + long-leg plaster casts (usually 4-7 casts)
90% of patients undergo percutaneous Achilles tenotomy at the end to address equinus
Final cast in 70 degrees of abduction
Foot abduction brace (Denis Browne splint): full-time for 3 months, then night/nap use for 3 years
Brace non-compliance is the #1 cause of recurrence

Complications of Ponseti

Recurrence (most common) - re-cast, may need tibialis anterior transfer
Rocker-bottom deformity - from correcting equinus before varus
Flat-top talus - from aggressive dorsiflexion causing talar dome flattening

Operative Treatment (only ~5% of idiopathic CTEV)

Reserved for resistant/refractory cases:

Age	Procedure
<1 year (failed Ponseti)	Posteromedial soft tissue release (PMR/Cincinnati approach) - tendon lengthening + subtalar, tibiotalar, talonavicular release
3-10 years	Medial opening-wedge osteotomy, lateral column-shortening osteotomy, or cuboid decancellation
Late presentation / older child	Triple arthrodesis (subtalar + talonavicular + calcaneocuboid fusion)

Surgical caution: protect the posterior tibial artery - the dorsalis pedis is often absent or inadequate in CTEV.

Prenatal Diagnosis

Diagnosed on antenatal ultrasound (18-24 weeks)
Look for fixed position of foot with toes pointing medially
Bilateral clubfoot increases risk of aneuploidy/genetic syndrome
Amniocentesis NOT recommended for isolated clubfoot
75% of complex clubfoot cases diagnosed at 18-24 weeks

Quick Summary Card

CTEV = CAVE deformities
       (Cavus + Adduction + Varus + Equinus)

Epidemiology:
  2:1 males | 50% bilateral | 1-2/1000 births

X-ray:
  Parallelism of talus + calcaneus
  Talocalcaneal angle <20° (AP)

Treatment:
  Ponseti casting → order = CAVE
  90% need Achilles tenotomy
  Brace 3 years post-casting
  Only 5% need surgery

Never correct E before V → rocker-bottom!

Miller's Review of Orthopaedics, 9th Ed.
Schwartz's Principles of Surgery, 11th Ed.
Creasy & Resnik's Maternal-Fetal Medicine

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