What is the Rule of Nines. How is it used to assess burn severity in adults. Why is accurate burn assessment crucial for treatment. When should alternative methods be considered. How does the Rule of Nines compare to other assessment techniques.

Understanding the Rule of Nines for Burn Assessment

The Rule of Nines is a widely used method for estimating the total body surface area (TBSA) affected by burns in adult patients. This quick and straightforward technique divides the body into sections, each representing approximately 9% of the total surface area. Healthcare professionals use this system to rapidly assess burn severity and determine appropriate treatment protocols.

Key Components of the Rule of Nines

• Head and neck: 9%
• Each arm: 9%
• Chest: 18% (9% front, 9% back)
• Abdomen: 18% (9% front, 9% back)
• Each leg: 18% (9% front, 9% back)
• Genitals: 1%

How accurate is the Rule of Nines? While it provides a quick estimate, it’s important to note that this method is most accurate for adults with average body proportions. Variations in body shape, size, and age can affect the precision of the assessment.

Clinical Applications of the Rule of Nines

The Rule of Nines plays a crucial role in the initial assessment and management of burn patients. By providing a rapid estimation of burn severity, it helps healthcare providers make critical decisions regarding treatment strategies, fluid resuscitation, and potential transfer to specialized burn centers.

When to Use the Rule of Nines

1. Emergency triage situations
2. Initial burn assessment in hospitals
3. Pre-hospital care settings
4. Determining the need for specialized burn center referral

Can the Rule of Nines be used for all types of burns? While it’s primarily used for thermal burns, the Rule of Nines can also be applied to chemical and electrical burns. However, healthcare providers should consider additional factors specific to these burn types when developing treatment plans.

Limitations and Considerations of the Rule of Nines

Despite its widespread use, the Rule of Nines has some limitations that healthcare professionals must consider. Understanding these constraints is essential for accurate burn assessment and appropriate patient care.

Potential Drawbacks

• Less accurate for children and infants
• May overestimate or underestimate in obese or very thin patients
• Does not account for varying thickness of burns
• Potential for human error in estimation

How can healthcare providers mitigate these limitations? Combining the Rule of Nines with other assessment methods, such as the Lund-Browder chart or computer-aided estimation tools, can help improve accuracy and provide a more comprehensive evaluation of burn severity.

Alternative Methods for Burn Assessment

While the Rule of Nines is a valuable tool, other methods exist for assessing burn severity. Understanding these alternatives can help healthcare providers choose the most appropriate technique for each patient and situation.

Lund-Browder Chart

The Lund-Browder chart is considered more accurate than the Rule of Nines, especially for children. It takes into account the changing body proportions as a person ages, providing a more precise estimation of TBSA affected by burns.

Palmar Method

This technique uses the patient’s palm (including fingers) as a reference, representing approximately 1% of their total body surface area. It’s particularly useful for assessing smaller or scattered burns.

Computer-Aided Estimation

Advanced software and mobile applications have been developed to assist in burn assessment. These tools often use body mapping and digital imaging to provide more accurate TBSA calculations.

Which method is best for burn assessment? The choice depends on various factors, including the patient’s age, body type, burn pattern, and the clinical setting. In many cases, a combination of methods may provide the most comprehensive evaluation.

Importance of Accurate Burn Assessment

Precise estimation of burn severity is crucial for several reasons, directly impacting patient care and outcomes. Understanding the significance of accurate assessment emphasizes the need for proper training and the use of appropriate tools.

Key Reasons for Accurate Assessment

• Guides fluid resuscitation protocols
• Determines the need for specialized burn center care
• Informs wound management strategies
• Assists in predicting potential complications
• Helps estimate recovery time and rehabilitation needs

How does inaccurate burn assessment affect patient care? Overestimation can lead to excessive fluid administration and unnecessary transfers to burn centers, while underestimation may result in inadequate treatment and delayed specialist intervention. Both scenarios can potentially compromise patient outcomes and increase healthcare costs.

Training and Education for Burn Assessment

Proper training in burn assessment techniques, including the Rule of Nines, is essential for healthcare providers working in emergency medicine, critical care, and burn units. Continuous education and practical experience can significantly improve the accuracy and consistency of burn evaluations.

Key Components of Burn Assessment Training

1. Understanding anatomy and body proportions
2. Practical application of various assessment methods
3. Recognition of burn depths and patterns
4. Interpretation of assessment results for treatment planning
5. Awareness of potential errors and limitations in estimation techniques

How can healthcare institutions improve burn assessment skills among their staff? Regular training sessions, simulations, and case studies can help maintain and enhance proficiency in burn assessment. Additionally, interdisciplinary collaboration and knowledge sharing between emergency departments, burn units, and pre-hospital care providers can lead to more standardized and accurate assessments.

Future Developments in Burn Assessment

As medical technology advances, new methods and tools for burn assessment are emerging. These innovations aim to improve accuracy, speed, and consistency in evaluating burn severity, potentially revolutionizing patient care in burn management.

Emerging Technologies

• 3D scanning and imaging for precise TBSA calculation
• Artificial intelligence-assisted burn assessment
• Telemedicine platforms for remote expert consultation
• Wearable devices for continuous monitoring of burn wounds
• Virtual and augmented reality tools for training and assessment

How will these advancements impact burn care? Improved accuracy in burn assessment can lead to more personalized treatment plans, better resource allocation, and potentially improved patient outcomes. However, it’s crucial to balance technological innovation with clinical expertise and judgment.

Integrating the Rule of Nines with Holistic Patient Care

While the Rule of Nines and other assessment methods are valuable tools, it’s essential to remember that burn care extends far beyond initial TBSA calculations. A comprehensive approach to burn management considers various factors that influence patient outcomes and recovery.

Elements of Holistic Burn Care

1. Psychological support and mental health care
2. Pain management strategies
3. Nutritional support and metabolic considerations
4. Infection prevention and control
5. Early mobilization and rehabilitation
6. Long-term scar management and reconstructive options

How does accurate initial assessment contribute to long-term patient care? Precise burn evaluation sets the foundation for a tailored treatment plan, allowing healthcare providers to anticipate potential complications, allocate resources effectively, and establish realistic recovery goals. This holistic approach, starting with tools like the Rule of Nines, ultimately aims to improve not just survival rates but also the quality of life for burn survivors.

In conclusion, the Rule of Nines remains a valuable tool in the initial assessment of burn patients, providing a quick and accessible method for estimating burn severity. However, healthcare providers must be aware of its limitations and consider using it in conjunction with other assessment techniques and emerging technologies. As burn care continues to evolve, the integration of accurate assessment methods with comprehensive, patient-centered care approaches will be crucial in optimizing outcomes for individuals affected by burn injuries.

definition of rule+of+nines by Medical dictionary

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[PDF] Lund and Browder chart—modified versus original: a comparative study

• DOI:10. 4266/acc.2019.00647
• Corpus ID: 208626187

@article{Murari2019LundAB,
  title={Lund and Browder chart—modified versus original: a comparative study},
  author={Arun Murari and Kaushal Singh},
  journal={Acute and Critical Care},
  year={2019},
  volume={34},
  pages={276 - 281}
}

• A. Murari, Kaushal Singh
• Published 1 November 2019
• Medicine, Business
• Acute and Critical Care

Background The Lund and Browder (LB) chart is currently the most accurate and widely used chart to calculate total body surface area affected by a burn injury. However, it is not easy to use charts to calculate burn percentages because of the difficulty in performing mathematical calculations with the percentages attributed to various body regions that are only partially burned. It is also cumbersome to have to perform mental calculations, especially in emergency situations. Methods We compared… 

A 1% TBSA Chart Reduces Math Errors While Retaining Acceptable First-Estimate Accuracy

William C Ray, Adrian Rajab, R. Fabia

Medicine

Journal of burn care & research : official publication of the American Burn Association

• 2021

A validated, simplified burn chart that minimizes one of the largest sources of random errors in %TBSA-burned estimates—simple calculation errors—while also being quick and requiring little training is presented.

EasyTBSA as a method for calculating total body surface area burned: a validation study

Cindy D Colson, Emily C. Alberto, R. Burd

Medicine

Emergency Medicine Journal

• 2023

The aims of this study were to assess the accuracy of the EasyTBSA application and compare its performance to three established methods of burn size estimation (Lund- Browder Chart, Rule of Nines and Rule of Palms).

Temporal trends in burn size estimation and the impact of the NSW Trauma App on estimation accuracy.

Thanya Sritharan, M. Haines, Varun Harish

Medicine

Burns : journal of the International Society for Burn Injuries

• 2023

Body mapping chart for estimation of percentage of body surface area in mesocephalic dogs.

Andrea Henriksson, Kendon W Kuo, Rachel S Moon

Medicine

Journal of veterinary emergency and critical care

• 2021

The most considerable differences between dogs and people in respect to the Rule of Nines chart were noticed in the head, the pelvic limbs, as well as in the groin region in people as compared with the pelvic/tail area in dogs.

To compare the effect of sea buckthorn and silver sulfadiazine dressing on period of wound healing in patients with second‐degree burns: A randomized triple‐blind clinical trial

M. Abdullahzadeh, Saeedeh Shafiee

Medicine

Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society

• 2021

It was concluded that using sea buckthorn dressing by reducing the period of wound healing can shorten the course of treatment of second-degree burns as well as reduce the burden of care in health care services.

Assessment of Nursing Care Provided to Hospitalized Children Burn Patients at Burn and Plastic Surgery Center at Kirkuk City

Aram Najat Abdulrazzaq, Hewa Sattar Salih

Medicine

Medico Legal Update

• 2021

The most striking results emerged from the data is that the majority of the participants have a good level of the practices in relation to nursingmanagement of major burns at admission, and a significant association is shown between nurses’ practices at admission and their age, gender, number of courses training.

Estimation of percent body surface area in cats with use of computed tomography.

Andrea Henriksson, Jack Hamersky, Kendon W Kuo, K. Gerken, Rachel S Moon

Medicine

Journal of veterinary emergency and critical care

• 2022

The distribution of BSA between body parts is different in cats compared to dogs and people, and a species-specific chart was created to assure a more accurate estimation of B SA in cats.

Laboratory Predictors for Morbidity and Mortality after Thermal Burns in Pediatrics

Mohamed Ebrahim Matar, Ahmed E. Elsharkawy, W. Mahmoud, Mohamed A. Elheniedy

Medicine

Journal of Advances in Medicine and Medical Research

• 2022

CRP, serum albumin, platelet count, serum creatinine and urea are good predictors of sepsis, AKI and mortalities after moderate to severe burn in pediatrics.

State of the Art: An Update on Adult Burn Resuscitation

Jacqueline M. Causbie, L. Sattler, A. Basel, Garrett W. Britton, L. Cancio

Medicine

European Burn Journal

• 2021

An update on fluid resuscitation techniques in burn patients is provided, to include choosing the initial fluid infusion rate, using alternate endpoints of resuscitation, and responding to the difficult resuscitation.

Effect of Different Itraconazole Dosing Regimens on Cure Rates, Treatment Duration, Safety, and Relapse Rates in Adult Patients With Tinea Corporis/Cruris: A Randomized Clinical Trial.

A. Khurana, Aastha Agarwal, Nirmala Mehta

Medicine, Psychology

JAMA dermatology

• 2022

High overall efficacy was observed among the 3 itraconazole doses for treatment of TCC, but with prolonged treatment durations and considerable relapse rates, according to this randomized clinical trial.

A modified Lund and Browder chart

A. Murari

Medicine

Indian Journal of Plastic Surgery

• 2017

The conventional (adult) LB chart has anterior and posterior body schematics divided into regions which represent percentages of total body surface area. These regional percentages are often in…

The 101 percent in Lund-Browder charts–a commentary.

K. Lundin, B. Alsbjørn

Medicine

Burns : journal of the International Society for Burn Injuries

• 2013

A critical evaluation of the Lund and Browder chart

D. Miminas

Medicine

• 2007

Important clinimetric properties that are applicable to the Lund and Browder chart, such as its reliability, concurrent and construct validity, acceptability and readability will be evaluated and weaknesses will be identified.

Comparison of the Lund and Browder table to computed tomography scan three-dimensional surface area measurement for a pediatric cohort.

R. Rumpf, W. Stewart, R. Fabia

Medicine

The Journal of surgical research

• 2018

The determination of total burn surface area: How much difference?

M. Giretzlehner, J. Dirnberger, R. Owen, H. Haller, D. Lumenta, L. Kamolz

Medicine

Burns : journal of the International Society for Burn Injuries

• 2013

A METHOD OF ESTIMATING THE EXTENSIVENESS OF LESIONS (BURNS AND SCALDS) BASED ON SURFACE AREA PROPORTIONS

S. G. Berkow

Medicine

• 1924

The extensiveness of a lesion may determine its seriousness in burns and scalds and factors in the body surface must maintain a constant relation to each other to express such relationship.

Burn area measurement by computerized planimetry.

C. Scott-Conner, K. M. Clarke, H. F. Conner

Medicine

The Journal of trauma

• 1988

Computerized planimetry provides a rapid, simple method of recording data and calculating total per cent burn which compares well with the manual Lund and Browder diagram.

The validation study on a three-dimensional burn estimation smart-phone application: accurate, free and fast?

A. K. Cheah, T. Kangkorn, E. Tan, M. L. Loo, S. Chong

Medicine

Burns & Trauma

• 2018

The validation study has shown that the 3D Burn application is useful in improving the accuracy of TBSAB measurement, and time of using the application was found to be significantly longer than traditional methods of estimation.

3D photography is as accurate as digital planimetry tracing in determining burn wound area.

K. Stockton, C. M. McMillan, K. Storey, M. David, R. Kimble

Medicine

Burns : journal of the International Society for Burn Injuries

• 2015

Smartphones and burn size estimation: “Rapid Burn Assessor”.

L. Kamolz, D. Lumenta, M. Giretzlehner

Medicine

Annals of burns and fire disasters

• 2014

This method represents a simple and ready-to-use clinical decision support system which addresses common errors associated with estimations of Burned BSA (=numerator) and could be deployed for testing in future clinical trials.

§3.2. Lever rule.

Using diagrams
state, you can determine the ratio
between weight quantities of coexisting
phases for an alloy of a given composition at
given temperature.

Lever rule
can only be used for two-phase
area .

To be able to
use the rule of thumb
the diagram needs to be
weight percent scale.

Let’s take two alloys
(1 and 2) at some temperature T.
The intersection of the ordinates of the alloys and the given
temperature will give us points b
and c. Let’s carry out a horizontal
line until it intersects with the chart lines.
Such a horizontal is called konoda .

For alloy 1
Let us determine the masses of coexisting phases.
These are the phases: liquid and solid crystals
A.

According to the rule of leverage
mass ratio of liquid and solid phases
can be written like this:

.
You can relate the mass of each phase to the mass
alloy, which will be required
in the task, then:

And

.

For alloy 2 –
similarly.

.
Also

And

.

From here it is clear what
the closer the alloy is to eutectic, the more
the proportion of the liquid phase at a given temperature.

Example1.

How many grams
gold is in the liquid phase of the alloy,
containing 30 wt.% Au,
at a temperature of 800С,
if the mass of the alloy is 400 g. On the diagram
weight percentages are indicated.

Find
point on the diagram, we draw a konoda to
intersection with the liquidus line, we define
weight percent. Konodu can
sketching is more
comfortable.

According to the rule of leverage
mass of the liquid phase (L)
will correspond to the segment ab,
and the mass of the entire alloy is the segment ad.

Thus,
the mass of the liquid can be calculated:

Mass of gold in
liquids can be calculated like this:

Number calculation
degrees of freedom

Let’s calculate the number
degrees of freedom for points specified
on the diagram.

S=K-F+1

Point 1 – point
melting component A.

Component
-1 (pure A), and two phases – pure solid
A and liquid A. Then C=1-2+1=0.

Point
2 – components -2 (A and B) and phases – 2, because V
This point already contains the first
crystals A. C=2-2+1=1.

Point
3 – components – 2 (A and B), and phase 1 (L).
C=2-1+1=2.

Point
4 – similar to point 2. Components – A
and B, phases – L and A. C \u003d 2-2 + 1 \u003d 1.

Point 5 – belongs
eutectic horizontal, flows
reaction LA+B.
Thus, there are 2 components (A and B), and
phases – 3, those that participate in the reaction
(L, A, B).
C=2-3+1=0.

Points 6 and 7 are similar
points 2 and 4. С=2-2+1=1.

Point 8 is similar
point 1, only this is the melting point
component B, not A. C=1-2+1=0.

Point 9 – component
-1 (B), the phase is also the same (solid B). C=1-1+1=1.

Point 10 is similar
point 9 – 1 component (A) and one phase
(solid A). C=1-1+1=1.

§3.3. The second type of charts. Components a and b are infinitely soluble in each other both in liquid and solid states and do not form chemical compounds with each other.

Systems of such
types are usually formed close in
inherently components (for example,
Sb-Bi, Au-Ag
etc. ).

top line
diagrams, as well as in the first type –
liquidus line. Above it exists
only liquid. bottom line – line
solidus. Below it there is only
solid phase. In this case, we have designated
her S. This is a continuous series
solid solutions of components in each
other (usually solid solutions
substitutions).

Cooling curves
were built for three alloys. For
pure A, pure B and n ₁ ,
located in the middle.

Cooling curves
for pure components are similar
considered for the first type of diagrams,
they have one pad at a temperature
melting components. When cooling
melt n ₁ to
temperature T ₁ starts
solid solution crystallization, and
cooling slows down (kink on
crooked). After the end of crystallization
(the composition of the solid phase is the same as the original
liquid composition) cooling rate
increases again and appears on the curve
second break. Cooling curves of all
alloys in this system are similar to each other
to each other and differ only in temperature
beginning and end of crystallization.

In those cases
when the components have close temperatures
melting, equilibrium diagrams
of the considered type are often characterized
having highs and lows. Alloy,
which has composition corresponding to the point
extremum, crystallizes at
constant temperature without change
composition.

what is it and how to use it

Scrum

Burndown Charts are a handy tool for monitoring project progress and monitoring plan execution. We tell you how to read them correctly and use them in your work.

Daria Lebedeva

July 15, 2022
• 5 min read

What is a task burndown diagram?

This is a method of monitoring the progress of a project and recording the remaining time to work on its backlog (remaining tasks). Thanks to the charts, it is easy to see if the work is going according to plan and if there are any delays.

The burndown chart is used by Scrum team leaders to monitor:

• the remaining tasks in the project;
• for the time needed to complete these tasks.

The Scrum methodology uses two types of Task Burndown Charts:

• Sprint Burndown — to monitor the amount of work left in a specific sprint;
• project burn – to keep track of the remaining work in the project.

How to work with a burndown chart?

A task burndown chart is a graphical representation of the remaining work within a given time frame for a project.

What it looks like:

Combustion graph in Kaiten

The project start point is in the upper left corner, the project end point is in the lower right.

The Y-axis shows the amount of work left (number of cards or tasks). The x-axis shows the time allotted for the sprint.

In addition to the axes, there are two lines on the chart:

• Blue is the ideal working line. It connects the start and finish points of the project. This is a rough analysis of the scope of work done during the sprint planning phase and an estimate of how your project will develop if everything goes according to plan.
• Orange – current working line. It shows the progress of the project. Even though the starting points of both lines are the same, their trajectories are likely to be different. This is due to the fact that the speed of tasks changes from day to day, and the actual work line rises above the ideal, then falls below it.

Project managers use the ideal line as a way to monitor. For example, if the actual line of work is higher than the ideal, the pace of work is slower than expected at the planning stage. And vice versa, if the current one is lower, then the tasks are completed faster. The goal is to follow the perfect line and keep up the intense pace of the work.

How to interpret the ratio of the actual and ideal working lines

This graph shows that the work is slower. than planned.

• Actual workline is below ideal – at this point in time there are fewer tasks left for the project than expected. You are ahead of schedule;
• actual working line is higher than ideal – work is slower than planned. You are behind schedule.

Note: It is best to use story points to indicate the complexity of tasks on a burndown diagram.

Story points are a relative estimate of the difficulty of each task in a project. It is also called task size.

Each team has its own evaluation system that suits them. Usually, Fibonacci ordinal numbers (1,2,3,5…) are used for marks on the line of ideal work.

Kaiten has a special field to indicate the size of each task in Story points.

How are Burndown charts different from Burnup charts?

Both are used for efficient workflow management. But these diagrams are not the same. The differences are as follows:

• burndown chart helps you track the amount of work done, predict the progress of tasks and monitor how much time they take;
• The burnup chart shows how much work has already been done and helps motivate the team by showing progress on the project.

Why burndown charts are an important part of the Scrum methodology

Monitoring project progress

Charts allow the team to monitor the progress of the project on a daily basis and check for compliance with the plan. For example, if the current work line is higher than the ideal, you will have to put in more effort to complete your tasks faster.

Sprint Tracking

Burndown charts are used to track daily sprint progress. This micro-level observation is necessary when you need to enable new user stories and close a sprint iteration quickly.

Monitor the overall progress of the project

The burndown chart of the project is updated every day, so it perfectly displays the overall progress of all sprints. Because the Scrum methodology is based on incremental, feedback-driven development, charts can help manage timelines even as new user stories are added to the project.

Three Key Benefits of Using Burndown Charts

Recent studies have shown that 39% of Russians have experienced burnout at work. This state may be due to a lack of understanding of the effectiveness of their work and the lack of appropriate tools for its implementation. Burndown charts help employees avoid burnout.

The main advantages of burndown charts:

1. Tracking progress easily and quickly is an undoubted advantage of burndown charts. They show how much work has been done and how much is left. Charts allow you to quickly analyze how many unresolved tasks fall on the remaining period of time.
2. Problems can be prevented. Since the burndown chart is updated daily, project hitches are easy to identify when analyzing it or during team meetings. With this approach, the problem can be seen and fixed before it becomes something serious.
3. They are easy to learn and understand. Unlike other graphs, burndown charts don’t track hundreds of different things. Their task is to compare the expected progress with the current one. Thanks to this, diagrams are easy to use in your work.

Burndown chart limitations

While useful, burndown charts are not perfect. It is worth remembering two things:

1. It all depends on the exact planning of the sprint. If the sprint is not planned correctly, the chart will not show accurate data. For example, if you underestimate the deadline, you will fall behind the schedule despite your best efforts. However, if you give yourself too much time, the team may mistakenly think they are ahead of the curve.
2. The ideal workline does not include new backlog items. The burndown chart shows only story points added to it for current tasks. At the same time, new backlog items that arise during the work on the project are not taken into account.

However, despite the shortcomings, Burndown Charts are worth learning and putting into practice if you want to implement Scrum.

How to use a burndown chart in Kaiten

Kaiten allows you to create detailed burndown charts for your sprints.

To view the burndown chart and other sprint reports in Kaiten, you need to use sprint boards in your work.

List the scheduled tasks on the board and start the sprint.

There are two ways to open a combustion graph in Kaiten:

• through the general report panel;
• or by clicking on the sprint itself and then on the “Combustion” item.

In addition to the number of cards (tasks) and the time allocated for the sprint, Kaiten also has a scale on the chart showing the size (difficulty) of the cards.

The graph shows that the team is behind the plan – the orange and green lines are above the dotted (ideal lines). You can see how many tasks have been completed and how many have been added.

Therefore, in addition to the ideal work line (blue dotted line) and the actual work line (orange line), the burndown graph in Kaiten shows:

This allows you to track progress more accurately.

Here, on the graph, you can see on which day how many tasks were completed (lilac columns) and how many tasks were added to the sprint outside the plan (red column).