How is total body surface area determined in burn patients. What are the primary methods for calculating burn percentage. Can smartphones improve burn size estimation accuracy. How does the Rapid Burn Assessor app work for TBSA calculations.

Understanding Total Body Surface Area (TBSA) in Burn Assessment

Total body surface area (TBSA) is a critical metric used by medical professionals to evaluate the severity of burns. An accurate TBSA calculation is essential for determining appropriate fluid resuscitation, transfer decisions, treatment protocols, prognosis, and research parameters. The speed and precision of this initial assessment can significantly impact patient outcomes throughout their healthcare journey.

There are three primary methods traditionally used to calculate TBSA:

• Lund and Browder Chart
• Wallace Rule of Nines
• Palmer Method

Each approach has its own strengths and limitations in assessing burn injuries. Let’s explore these methods in detail and examine how modern technology is revolutionizing TBSA calculations.

The Lund and Browder Chart: Detailed But Complex

The Lund and Browder (LB) chart is widely regarded as the most accurate traditional method for calculating TBSA. It utilizes anterior and posterior diagrams of the human body, assigning specific percentages to different body regions ranging from 1-13%.

How does the Lund and Browder chart work?

Medical staff examine the burn injury and add up the percentages for each affected body region to determine the total TBSA. While this method offers precision, it does have some drawbacks:

• Requires quick mental calculations
• Can lead to variability between different assessors
• May be time-consuming in emergency situations

Despite these challenges, the LB chart remains a valuable tool in burn assessment, particularly for more complex cases or when time permits a thorough evaluation.

The Wallace Rule of Nines: Quick But Less Precise

The Wallace Rule of Nines is commonly employed for assessing second- and third-degree burns. This method divides the body into sections, each representing a multiple of 9% of the total body surface area.

What are the percentages used in the Rule of Nines?

For adults, the Rule of Nines typically assigns the following percentages:

• Head and neck: 9%
• Each arm: 9%
• Each leg: 18%
• Anterior trunk: 18%
• Posterior trunk: 18%
• Genitalia: 1%

The simplicity of this method allows for rapid assessments in emergency situations, enabling quick decisions about fluid replacement and level of care required. However, it’s important to note that these percentages are approximations and may not be as accurate for all body types or for children.

The Palmer Method: Simple But Potentially Inaccurate

The Palmer Method uses the patient’s palm as a reference measurement for calculating burn size. The area from the wrist to the fingertips is considered to represent approximately 1% of the total body surface area.

What are the limitations of the Palmer Method?

While the Palmer Method offers a quick and easy way to estimate TBSA, it has several significant drawbacks:

• It can lead to overestimations of 10-20%
• The average adult’s hand actually represents about 0.78% of TBSA
• In children, the hand typically represents more than 1% of TBSA

Due to these inaccuracies, the Palmer Method is best suited for estimating small burns and should be used cautiously for larger areas.

Introducing the Rapid Burn Assessor: Smartphone Technology for TBSA Calculation

As technology advances, new tools are emerging to improve the accuracy and consistency of TBSA calculations. One such innovation is the Rapid Burn Assessor, a smartphone application designed to streamline and enhance burn size estimation.

How does the Rapid Burn Assessor work?

The Rapid Burn Assessor utilizes the smartphone’s camera and advanced image processing algorithms to calculate TBSA. Here’s a brief overview of the process:

1. The healthcare provider takes photos of the burn injury from multiple angles
2. The app uses 3D modeling to map the burn onto a digital representation of the human body
3. Advanced algorithms calculate the TBSA based on the mapped burn areas
4. Results are displayed quickly, providing a more accurate and consistent assessment

This technology aims to combine the speed of traditional methods with the precision of digital measurements, potentially revolutionizing initial burn assessments in emergency settings.

Benefits of Using Smartphone Technology for Burn Assessment

The integration of smartphone apps like the Rapid Burn Assessor into burn care protocols offers several advantages over traditional methods:

What improvements does digital TBSA calculation offer?

• Increased accuracy: Digital measurements reduce human error and variability between assessors
• Consistency: Standardized algorithms ensure uniform calculations across different cases and facilities
• Speed: Quick results allow for faster decision-making in critical situations
• Documentation: Digital records can be easily stored and shared with the healthcare team
• Education: Visual representations can aid in patient and family understanding of the injury

By leveraging the power of smartphones and 3D modeling, medical professionals can potentially improve patient outcomes through more precise treatment planning and resource allocation.

Challenges and Considerations in Implementing Digital Burn Assessment Tools

While smartphone-based TBSA calculation tools offer numerous benefits, their implementation in clinical settings comes with certain challenges:

What obstacles might hinder adoption of digital burn assessment methods?

• Training requirements: Staff need to be properly trained in using the new technology
• Cost: Implementing new systems and maintaining devices can be expensive
• Privacy concerns: Ensuring patient data security on mobile devices is crucial
• Reliability: Dependence on technology requires backup plans in case of system failures
• Resistance to change: Some healthcare providers may be hesitant to adopt new methods

Addressing these challenges will be crucial for the widespread adoption and success of digital burn assessment tools in clinical practice.

The Future of Burn Assessment: Integrating Technology and Expertise

As we look to the future of burn care, it’s clear that technology will play an increasingly important role in assessment and treatment planning. However, it’s important to recognize that these tools are meant to augment, not replace, clinical expertise.

How can technology and clinical judgment work together in burn assessment?

The ideal approach to burn assessment likely involves a combination of:

• Digital tools for rapid, accurate TBSA calculations
• Traditional methods as a backup and cross-reference
• Clinical experience to interpret results and make informed decisions
• Ongoing research to refine and improve assessment techniques

By integrating cutting-edge technology with established medical knowledge, we can strive for more precise, consistent, and effective burn care protocols.

As the field of burn assessment continues to evolve, it’s crucial for healthcare providers to stay informed about new developments and tools. The Rapid Burn Assessor and similar smartphone applications represent an exciting step forward in improving the accuracy and efficiency of TBSA calculations. However, it’s important to remember that these tools are just one part of a comprehensive approach to burn care.

Ultimately, the goal of any burn assessment method – whether traditional or technology-driven – is to provide the best possible care for patients. By embracing innovation while maintaining a strong foundation of clinical expertise, the burn care community can continue to improve outcomes and support survivors throughout their recovery journey.

Defining Total Body Surface Area (TBSA)

Article

Written on April 19, 2022

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Burn Treatment

Burn Wounds

Getting Quality Treatment

Optimal Burn Care

One of the most common phrases you’re likely to come across throughout the burn treatment process is total body surface area (TBSA). TBSA is a tool medical professionals use to assess the severity of a patient’s burns. The speed and accuracy of this initial assessment is critical because it informs all steps of the patient healthcare journey, including fluid resuscitation, transfer decisions, management, prognosis, and research.

There are three primary methods of calculation. Each has its own grading system, use case, and pros and cons. In this article, we’ll take a closer look at these three methods of assessing TBSA. Equip yourself with the knowledge you need to understand and ask questions about your treatment and recovery.

How Is the Total Body Surface Area Determined?

To calculate TBSA, doctors and nurse practitioners focus on three main methods: Lund and Browder, Wallace Rule of Nines, and the Palmer Method.  

Lund and Browder Chart

The first method of burn assessment uses the Lund and Browder (LB) chart. The LB chart shows both anterior and posterior diagrams of the human body and assigns percentages to each region of the body, from 1-13 percent. As medical staff members examine the burn injury, they add up the percentages of each body region to calculate the severity of all injuries. 

Lund and Browder is considered the most accurate of these three methods, but the LB chart still has its limitations. This method requires quick mental calculation. Ease of use is also a concern as medical staff members may come up with different TBSA calculations. This is why it’s so important that TBSA formulas are precise, reliable, and repeatable. 

Wallace Rule of Nines

The Wallace Rule of Nines is most often used for second- and third-degree burn injuries. Every burned portion of the body is counted by a multiple of nine. Each arm, for example, is assigned 9 percent; each leg is assigned 18 percent. A doctor or nurse practitioner can quickly add up the total body surface burned based on an initial visual examination. The table below from Healthline shows the Rule of Nines percentage points for adults: 

The advantage of using the Wallace Rule of Nines is that the estimation is a simple formula, and, therefore, it is easy to calculate the amount of fluid replacement (IVs) and level of care a patient will require. It offers quick assessments in emergency situations and empowers medical professionals to quickly relay burn injury measurements to the rest of the team. Because burn injuries with a percentage of 30-plus percent can be fatal, a quick response is critical. 

Palmer Method

The third method is known as the Palmer Method. Medical staff use the length of the patient’s palm (fingers together), not their own, as a reference measurement for calculating burn size and span. The length from wrist to finger = 1 percent TBSA. 

On one hand, the Palmer Method makes it easy to calculate quickly and assess a patient’s fluid resuscitation and care needs. On the other hand, the Palmer Method is far from perfect science. In fact, the average adult’s hand makes up 0.78 percent of their total body surface area. In most children, that same number is more than 1 percent. For this reason, the Palmer Method can lead to burn injury overestimations of anywhere from 10-20 percent. It’s important to remember that the Palmer Method is only a rough initial estimate and is best used for small burns. 

Methods of TBSA assessment continue to improve, thanks to 3D technology. Medical teams now have access to 3D models of human anatomy on desktop and mobile applications to quickly and accurately assess burn injuries. Full rollout and implementation is still in the works in hospitals and burn centers throughout the United States.

TBSA is just one of the first steps toward burn diagnostics, treatment, and recovery. Burn survivors can take additional steps on their own toward understanding, acceptance, and community-building as they come to terms with their injury on the road to healing.  

Phoenix Society offers a full library of resources from survivors and medical experts who understand what you’re going through. Looking for added support as you navigate the treatment and recovery process? Reach out today. 

How To Determine The Body Surface Area Of A Burn

How to determine the body surface area of a burn is vital during the initial management of treating burn victims. The measurement of burn surface area is important during the initial management of treating victims with burns for estimating fluid requirements and determining need for transfer to an emergency burns unit. The extent of injury is best described using the percentage of the total body surface area (%TBSA) that is affected by a burn. 

The “rule of palm” is one way to estimate the size of a burn.

HOW TO DETERMINE THE TBSA USING THE “RULE OF PALM”

• The palm of the person who is burned is about 1% of the body.
• This excludes the fingers and wrist area.
• Use the victim’s palm to measure their body surface area burned.

Rule of Palm

Estimation errors related to and/or based on incorrect %TBSA assessments may affect clinical decision-making and, in the extreme, can result in either hypovolemic shock and cardiac failure (under-estimation) or abdominal/extremity compartment syndrome, pulmonary edema and electrolyte imbalance (over-estimation).

TIPS – CALCULATING BODY SURFACE AREA

• With severe burn injuries (>50%TBSA) it maybe easier to calculate what isn’t burned then subtract it from 100 to get %TBSA burns
• Use the “rule of palm” method to calculate %TBSA for smaller burns. Remember to always use the patients hand, not your own.
• In the prehospital and emergency department setting, the %TBSA burns is more important than the depth of burn. %TBSA burns has indications for severity of injury, fluid resuscitation and transfer destination. Depth of the burn and burn wound progression becomes more significant after arrival at the Emergency Burn Unit as depth of burn will determine whether the burn can heal without surgical intervention, and how the Emergency Burn Unit will subsequently manage it.
• If %TBSA burn estimation is inaccurate it has the potential to negatively impact fluid resuscitation by providing too much or too little fluid.

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Resource: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396790/#B5; https://www.uofmhealth.org/;

Online test for emotional burnout

Test for burnout

Emotional exhaustion

0-27% is definitely not burnout nie.

28-44% – this is most likely not burnout, but there is a risk.

45-63% – with a high probability you burned out at work.

64% -100% – you are burning out, it’s time to do something about it!

Depersonalization

0-13% is definitely not burnout.

14% -40% – most likely this is not burnout, but there is a risk.

41% -50% – with a high probability you burned out at work.

51% -100% – you are burning out, it’s time to do something about it!

Professional achievements

77%-100% is definitely not burnout.

58%-76% – most likely this is not burnout, but there is a risk.

48-58% – with a high probability you burned out at work.

0-47% – you’re burning out, it’s time to do something about it!

At the end of the working week I feel emotional
empty, without vivid emotions and feelings

By the end of the working day I feel like a squeezed lemon

days off

The results of my work are not worth the effort that I spend

I am annoyed by my subordinates and colleagues who are slow or
incompetent

I feel energetic and emotionally uplifted

To agree and avoid conflicts

I feel a breakdown of strength and apathy in relation to my work

I can bring a “spark” to work and interest my colleagues

I have recently become more callous.

insensitive) in
relationships with colleagues

The people I work with are not interesting to me. They
make me tired rather than happy

I enjoy working and have many plans for the future related to
my professional development. I believe in their implementation

I have many disappointments in life

I feel indifference and loss of interest in many things that made me happy
earlier

I don’t care what happens to my colleagues. I prefer
formal communication with them, without unnecessary emotions, and I strive to bring
communication with them to a minimum

I want to retire and take a break from everything and everyone

I can easily create an atmosphere of goodwill and cooperation in
collective

I easily communicate with everyone at work (subordinates, colleagues, technical
personnel) regardless of their ambitions, emotional state and manner
communication

I am satisfied with my life and professional success
(achievements)

I feel overwhelmed

I can still do a lot in my life

I show more attention and care to my colleagues than I receive from them
appreciation and gratitude

Burnout syndrome: detection, stages and prevention

Recently, employers have come to understand that labor protection is not only about the absence of risks in the workplace and the ergonomics of the workspace, but also about the mental state of employees. Increasingly, people are turning to the term “burnout syndrome” to describe their exhaustion from work, but few really understand what it means. What kind of syndrome it is, what provokes it and how to avoid its development – we talk about this and not only in the article.

12/24/21

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Contents of the article

Reviews, interviews, latest news and changes in legislation – promptly in our Telegram channel. About the most important events – in our VKontakte group.

What is burnout syndrome?

The World Health Organization defines burnout syndrome (BSE) as a condition resulting from chronic workplace stress that has not been successfully managed. It is also caused and accompanied by a great emotional load.

Results of the international study STADA Group Health Report 2019
show that 72% of Russians have ever experienced burnout at work, but only 7% of respondents were able to correctly describe the symptoms of this condition – lack of motivation and insomnia. 65% of Russians mistakenly associate professional burnout with a complete loss of the ability to experience joy and happiness, as well as with erectile dysfunction and tinnitus.

Initially, this phenomenon was attributed only to workers in the communicative fields of activity: doctors, firefighters, policemen, and teachers. However, over time, studies have confirmed that those whose activities are not associated with frequent communication are also at risk – programmers, athletes, engineers and many others. From the so-called “pay for sympathy” burnout has become a widespread problem.

Occupational burnout syndrome is included in the 11th revision of the International Classification of Diseases, effective from January 1, 2022. The syndrome itself is not a diagnosis, but is classified as a factor affecting the health status of the population and access to healthcare facilities (included in the 24th class of the ICD 11 – approx. ed. ). Does this mean that the employer will be obliged to issue sick leave due to the development of this syndrome?

At the level of legislation, the employer is not obliged to monitor the level of happiness of his employees. But at the same time, he is obliged to comply with labor protection standards, which include, among other things, providing the employee with a normal load that will comply with the standards for observing the work and rest regime. SEV is being introduced into the international classification of diseases from January 1, 2022, so whether it will be possible to take sick leave will depend on changes in Russian legislation.

It is important to understand that burnout is a chronic, not an acute, condition in which mental disorders lead to somatic disorders that provoke absenteeism and dismissal.

Factors influencing the development of burnout syndrome

What influences the appearance and development of BS? Let’s highlight some of the factors that can lead to the development of burnout.

1. Lack of opportunities for personal career growth.

   Characterized by loss of involvement, low efficiency, drop in performance indicators.

2. Unfavorable working environment.

   Toxic attitude of colleagues, disrespect and other manifestations of unkindness at work.

3. Lack of professional recognition.

   Depreciation of the work of employees, insufficient recognition of the significance of the work performed has one of the highest percentages in studies of the reasons for voluntary dismissal.

4. Replacing personal life with work and non-compliance with working hours.

   An imbalance between professional and personal life is a direct path to burnout. So, in Asian countries, due to the labor mentality and unspoken social rules, a large percentage of overtime arises, which even lead to deaths in the workplace: in Japan they are called karoshi, in China – golaos, in Korea – kvaros (about this and much more about working in South Korea – in our article).

5. Dull or meaningless work.

   The inability to switch between tasks and a lack of understanding of the purpose of the work performed contribute to the emergence of cynicism and the reduction of professional achievements.

6. High responsibility with non-obvious results.

   Not just performers, but creators have a very high degree of uncertainty in their work and a high level of responsibility for making decisions, which provokes permanent stress.

7. Uncertainty.

   Lack of understanding of one’s clear tasks, deadlines and expectations from the results greatly undermines the emotional state of the employee.

8. Uncomfortable or dangerous working conditions.

   Unfavorable working conditions have a negative impact on the productivity of employees – for example, in a dark or noisy room it is more difficult to concentrate and more easily become stressed.

9. Psychological portrait of an employee.

   At risk are workaholics and careerists who are charged to devote themselves to the profession and do not allow themselves to relax once again.

12 phases of the development of the syndrome

American psychiatrist Herbert Freudenberger, together with his colleague Gale North, identified 12 phases of burnout, the symptoms of which should be paid attention to.

Phase 1. Self-affirmation. As a rule, burnout begins with a feeling of underestimation of one’s work and oneself by superiors, colleagues, clients / patients. A person understands that he needs to assert himself by working harder.

Phase 2. Work harder. In an attempt to compensate for the feeling of underestimation, a person begins to work harder, spending more resources.

Phase 3. Neglect of needs. As a result of increased workload, there are problems with sleep, nutrition and other needs, including social interaction – delays at work begin, the amount of communication with family and friends decreases.

Phase 4. Neglect of conflicts. After some time, the environment begins to notice that something is wrong with the person, tells him about it, but he is not receptive to comments from others in the early stages of burnout and avoids entering into conflicts on this basis.

Phase 5. Revisiting values. There is even greater distancing from the environment, work takes weekends and evenings, old values ​​​​like spending time with friends or doing hobbies are erased.

Phase 6. Denial of problems. It becomes more difficult to communicate with people, self-pity, cynicism and aggression appear.

Phase 7 Suspension. Social contacts are reduced to a minimum, all free time is filled with work. Behavioral deviations appear, health problems are clearly manifested.

Phase 8. Obvious changes in behavior. A person ceases to be the same as before, and this becomes obvious to everyone around, and not just to close people.

Phase 9. Depersonalization. The condition manifests itself in the loss of the ability to feel something, everything around is perceived as a dim gray picture, and in some forms of depersonalization, the loss of one’s own personality or its splitting (dissociation) occurs.

Phase 10. Internal void. At this stage, emptiness compensation mechanisms are activated – alcohol abuse, shopping addiction, stress eating or vice versa starvation. Of the most socially acceptable ways to relieve stress, there is a way to search for extreme sports and leisure activities, to go into virtual reality or go to work itself.

Phase 11. Depression. After unsuccessful attempts to fill the inner void, a phase of clinical depression begins. The meaning of existence is lost, there is no consolation and reasons for optimism.

Phase 12. Burnout syndrome. Accompanied by suicidal thoughts, deviations in mental and physical health. There is an urgent need for medical assistance.

How to recognize burnout?

The MBI (Maslach Burnout Inventory) method has been used for a long time to diagnose burnout in an international environment. It includes 22 statements about feelings and experiences related to work, and for each of them 6 ratings are offered – from “never” (0 points) to “everyday” (6 points). According to the total score, the state of the respondent is determined: depersonalization, reduction of professionalism (an attempt to reduce emotional contacts at work – approx. ed. ) or occupational exhaustion.

In Russian practice, for the diagnosis of burnout syndrome, a test by V. Boyko was developed, consisting of 84 questions that need to be answered “yes” or “no”. V. Boyko distinguishes three phases of the burnout syndrome: tension, resistance and exhaustion, and the test helps to determine in which phase the individual is and whether he is.

You can learn about the occurrence of burnout among employees from HR analysis: this will be indicated by high staff turnover and a decrease in performance indicators of both one unit and the company as a whole. An effective method would also be to conduct regular surveys to identify signs of BS in employees.

In addition to tests and surveys, burnout can be determined through medical diagnostics. With the help of an electroencephalogram (EEG), four main periodic rhythms of the brain are recorded, characterizing different states.

• alpha rhythm — state of calm wakefulness;
• beta rhythm – the state of active wakefulness (intense mental activity) and deep sleep;
• delta and theta rhythm – slow sleep and emotional reactions to negative situations.

A burnout marker is a violation in the display of the “calm” alpha rhythm – its decrease / absence or non-standard appearance. This may indicate a constant hyperactivity of the brain and processes responsible for emotions.

Magnetic resonance imaging (MRI) is another type of diagnostic that allows you to identify burnout syndrome. The limbic system of the brain (the amygdala, hippocampus, hypothalamus, and cingulate gyrus) is responsible for empathy, emotional regulation, and emotion recognition. Accordingly, a decrease in activity in these areas, monitored on MRI, can serve as a marker of burnout.

The cingulate gyrus is part of the limbic system (MRI image)

If you or someone from your environment shows signs of burnout, it would be right to contact (advise to contact) a psychologist or psychotherapist. Since burnout itself is not a mental disorder, it is not treated with medication – it is the work on oneself that is important here.

SEB prevention

SEB prevention levels can be divided into personal and organizational levels.

for personal level each employee, depending on the degree of his own awareness, can take a number of preventive measures to avoid the onset of the syndrome.

1. Establishing a work-life balance.

   To maintain health – both physical and mental – the body needs regular rest and the presence of interests outside of work.

2. Introduction of regular physical activity.

   Training and exercise give vent to emotions, especially negative ones, and accumulated stress.

3. Sleep mode.

   The hormone melatonin affects sleep, and its production is affected by light; for example, the blue glow of screens disrupts its functioning and leads to sleep disturbances.

4. Organizing your work.

   It is important to plan your schedule so that the work is distributed evenly, and not be in constant stress from deadline to deadline.

5. Switch between activities.

   Monotonous routine work is not good for the psycho-emotional state; try to add variety to work tasks.

6. Seeking help in a timely manner.

   Probably the most difficult step is to recognize and accept the problem in order to contact a specialist in time. In case of burnout development, complex treatment from a psychologist / psychiatrist is necessary.

SEB prevention should also be carried out at the organizational level.

1. Clearly set tasks and goals for employees.

   Planning eliminates or minimizes uncertainty, and as we have already found out, uncertainty is one of the risk factors for the development of SEB.

2. Settlement of work conflicts.

   Team building, training with a psychologist and much more – all this contributes to the formation of a healthy environment in the team. For the prevention of SEB among employees of communicative professions, the method of the Balint groups is popular, aimed at analyzing work situations that caused any difficulties in work.

3. Motivation.