Rule of nines burn chart: Burn Percentage in Adults: Rule of Nines Chart

08.08.202318.07.2023 by alexxlab

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What is the rule of nines, and how can it be applied in burn care?

The rule of nines is a method used to estimate TBSA, inform fluid resuscitation and initiate the patient transfer process. For patient safety, the rule of nines should only be calculated by healthcare professionals.

For Burn and Reconstructive Centers of America (BRCA), burn centers across our care system, emergency services personnel and many other facilities, the rule of nines is the foundation of emergency and pre-burn center care. The rule of nines is a method used to estimate Total Body Surface Area (TBSA), or the percentage of the body surface burned. Healthcare professionals typically use the rule of nines upon patient intake before starting fluid resuscitation.

Upon intake of a new burn patient, healthcare professionals will assess the patient for severe trauma that needs to be addressed before the burns and stabilize the patient. If there are no other traumatic injuries that need to be prioritized, then the burn care team will begin to treat the burn injuries. One of the first steps in emergency burn care is using the rule of nines to estimate the TBSA. The rule of nines is not used for every burn patient. It is typically used for calculating the most severe burn injuries, such as second-, third- and fourth-degree burns. First-degree burns are considered minor burns and generally don’t require medical attention, hospital transfer or fluid resuscitation.

When calculating the TBSA, the burn team or emergency services will use the rule of nines body chart as a guide. This chart shows the percentage of each body part, front and back. Each part of the body is broken up into increments of 9%, hence the rule of nines. For example, each adult arm counts as 4.5% for the front and 4.5% for the back, accounting for 9% for each arm out of a total of 100% of the entire body. Each adult leg counts as 9% for the front and 9% for the back, totaling 18% for the whole of each leg, and so on. When the burns are spread out, or there are burned patches here and there, it is common practice to use the size of the patient’s palm to calculate those areas with the palm counting as 1%.

The adult rule of nines is broken down as follows:

Head (including neck): 4.5% anterior (front) and 4.5% posterior (back) for a total of 9%
Each arm (including the hands): 4.5% anterior and 4.5% posterior for a total of 9% each
Torso: 9% anterior and 9% posterior for a total of 18%
Pelvis: 9% anterior and 9% posterior for a total of 18%
Genitalia: 1% anterior
Each leg (including feet): 9% anterior and 9% posterior for a total of 18% each

However, the adult rule of nines is not recommended for treating minors. For those pediatric patients, the rule of nines is adjusted for the proportional differences in the head, torso and legs.

The rule of nines for pediatric patients is broken down as follows:

Head (including neck): 9% anterior and 9% posterior for a total of 18%
Each arm (including the hands): 4.5% anterior and 4.5% posterior for a total of 9% each
Torso: 18% anterior and 18% posterior for a total of 36%
Each leg (including the feet): 7% anterior and 7% posterior for a total of 14% each

It’s important to note the distinctions between the adult and pediatric rule of nines. There are two main differences for children zero to nine years of age:

A child’s head is proportionally larger at birth and accounts for 18% of its body area. For each year over one year old, 1% should be subtracted from the head up to nine years old. The head of children ages ten and up should be calculated at 9%.
At the same time, 0.5% should be added to each leg for each year up to nine years old.

Once the TBSA has been calculated, the burn care team begins life-saving fluid resuscitation. Fluid resuscitation involves replacing or replenishing the body’s fluids lost during the burn injury using the preferred Lactated Ringers (LR) solution or Normal Saline if LR is not available. Fluid resuscitation aims to maintain blood circulation (perfusion) and organ function while avoiding inadequate or excessive fluid replacement. Proper fluid resuscitation is dependent on the accurate calculation of the patient’s TBSA. It’s crucial to accurately dose fluid, as an overloaded patient often experiences increased mortality and morbidity rates. Note, however, that not all burn patients need to be resuscitated. Burns under 10% TBSA do not require fluid resuscitation.

Using the rule of nines to estimate TBSA not only helps calculate proper fluid resuscitation but also sets the amount of intravenous (IV) access a burn patient needs (15% or more = at least one and 40% or more = at least two) and whether the patient needs to be transferred. The American Burn Association has established ten criteria for transferring a burn-injured patient for treatment. One of those ten criteria includes transferring those with partial-thickness burns with a ≥10% TBSA.

The move towards specialized burn care has enabled burn centers like those in BRCA’s system to research, implement and improve early resuscitation practices to avoid over-aggressive fluid treatment. If you have any doubts, please call a member of our burn team at 855-863-9595 or use our Burn App for quick provider-to-provider consultations. BRCA’s burn experts have treated tens of thousands of burn patients. They are available 24/7 to assist in ensuring the accuracy of fluid calculation and the general need for fluids.

More burn care resources for medical professionals can be found at burncenters.com or by clicking here.

Burns, Children, Adults, Wallace, and More

Rule of Nines: Burns, Children, Adults, Wallace, and More

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Medically reviewed by Alana Biggers, M. D., MPH — By Rachel Nall, MSN, CRNA — Updated on July 20, 2018

What is the rule of nines?

The rule of nines is a method doctors and emergency medical providers use to easily calculate the treatment needs for a person who’s been burned.

It’s sometimes referred to as the Wallace rule of nines after Dr. Alexander Wallace, the surgeon who first published the method. The creation of this method is credited to Pulaski and Tennison.

A medical professional will do a visual examination to look for seriously burned areas and use the rule of nines to quickly add up what percentage of a person’s body is burned. While doctors will perform more thorough examinations for burn estimation, they can use the rule of nines to quickly assess a person and start recommending treatment centers and interventions to help a person.

The rule of nines is meant to be used for:

second-degree burns, also known as partial-thickness burns
third-degree burns, known as full-thickness burns

The rule of nines assigns a percentage that’s either nine or a multiple of nine to determine how much body surface area is damaged. For adults, the rule of nines is:

A medical provider can use calculations from the rule of nines in several ways. This includes the amount of fluid replacement and degree of care a person needs.

When a person experiences a second-degree burn or worse, the protective layer of skin is destroyed. As a result, they’ll lose a significant amount of body water. This makes providing fluids vital to helping a person maintain their total body water. According to the National Institutes of Health, burns that are greater than 20 to 25 percent of total body surface area require significant intravenous (IV) fluids. Doctors will also use the estimated body surface area burned to determine how much fluid to administer.

The rule of nines can also relay to a medical team receiving the patient how serious the injury is. Providers also know that burns that exceed 30 percent of a person’s body can be potentially fatal, according to the National Institutes of Health.

If a person has burns on 10 percent of their body surface area or greater, a specialized burn center should treat their wounds. Other circumstances where a burn center should treat the wounds include:

when the person is a child
when the burned areas involve key areas of the body, such as the hands, feet, genitalia, face, or major joints
chemical burns
electrical burns
the presence of third-degree burns

Another example of how a provider may use the rule of nines is to determine how much IV access is needed. If a person has 15 percent or more of their total body surface area burned, they’ll need at least one peripheral line to provide IV fluids. If a person’s body is burned 40 percent or more, they’ll need at least two IVs.

Doctors don’t typically use the same calculations in the rule of nines to children. This is because children tend to have different body proportions than adults do, including larger heads and smaller legs. For example, children tend to proportionally have a 20 percent larger head than adults, according to the National Institutes of Health. Infants also have 13 percent smaller legs than adults.

Therefore, there are a few adjustments for the rule of nines in children:

Burns are a serious, painful injury that require immediate treatment and intervention. The rule of nines serves as a quick method of assessment for a medical provider to estimate the extent of a person’s injuries. If the person with burns is a child, the rule of nines should be adjusted due to differences in a child’s proportions.

Last medically reviewed on July 19, 2018

How we reviewed this article:

Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

Assessing burns and planning resuscitation: The rule of nines. (n.d.).
uwhealth.org/emergency-room/assessing-burns-and-planning-resuscitation-the-rule-of-nines/12698
Burn triage and treatment – Thermal injuries. (2017).
chemm.nlm.nih.gov/burns.htm
Helttiaratchy S. (2004). Initial management of a major burn: II—assessment and resuscitation. DOI:
10.1136/bmj.329.7457.101
Lee KC, et al. (2014). History of burns: The past, present and the future. DOI:
10.4103/2321-3868.143620
Quick reference guide: Burn stabilization. (n.d.).
uwmedicine.org/airlift-nw/Documents/burn-pocket-card-final.pdf

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Medically reviewed by Alana Biggers, M.D., MPH — By Rachel Nall, MSN, CRNA — Updated on July 20, 2018

Algorithm of action in case of burns – News

Burns are one of the most common fire injuries. Therefore, it is important for all of us to know the techniques and methods of providing first aid to victims of burns.

The tragic consequences of burns would have been much less if help had been provided correctly from the first minutes. It is enough to apply a scheme of actions available to everyone directly at the scene of the incident in order not only to reduce pain, but also to significantly increase the likelihood of saving the victim.

As a rule, burns received in a fire are thermal, that is, obtained from direct exposure to fire, hot metal objects, flashed combustible liquid. By the way, thermal burns also include injuries received from boiling water or hot water.

It is important to be able to distinguish between degrees of burns. There are 4 degrees of burns:

I degree – skin redness, swelling. The mildest degree of burn.

II degree – the appearance of blisters filled with a clear liquid (blood plasma).

III degree – necrosis of all layers of the skin. Proteins of skin cells and blood coagulate and form a dense scab, under which there are damaged and dead tissues.

IV degree – charring of tissues. This is the most severe form of a burn, in which the skin, muscles, tendons, and bones are damaged.

The first factor influencing the severity of the victim’s condition is the area of the burn. You can determine the area of the burn using the “rule of nines”: the skin surface of the palm is 1% of the body surface, the skin surface of the hand is 9%, the skin surface of the leg – 18%, the skin surface of the chest in front and behind – 9% each, the skin surface of the abdomen and lower back of the abdomen and lower back – 9% each. Burn of the perineum and genitals – 10% of the burn area. Burns in these areas are shock injuries. There are superficial and deep burns; limited (less than 10%) and extensive (more than 10%).

REMEMBER! With large burns, life-threatening dehydration occurs.

BURN SCHEDULE:

1. Stop exposure to high temperature on the victim, extinguish the flame on his clothes, remove the victim from the affected area.

2. Specify the nature of the burn (flame, hot water, chemicals, etc.), as well as area and depth. Wrap the victim in a clean sheet and immediately deliver to a medical facility.
3. Carry out transport immobilization, in which the burned areas of the body should be in the most stretched position.

4. With a small burn, the burnt area can be placed under a stream of cold water from a tap for 10-15 minutes, with extensive burns this should not be done.

5. It is better to cut the clothes in the places of the burn and apply an aseptic bandage around the burn, while cotton should not be applied.

6. When transporting the wounded to a medical institution, ensure that he is calm.

IT IS FORBIDDEN:
– to leave the victim alone;

– apply ointment, cream, vegetable oil to the burned area, sprinkle with powders;

– pierce bubbles;

– remove clothing from the burned area;

– in case of a burn of the oral cavity, give food and drink.

The Main Directorate of the Ministry of Emergency Situations of Russia for the Kabardino-Balkarian Republic reminds:

If you are in an emergency and you need the help of firefighters or rescuers – a single number to call all emergency services from the mobile phone “112” and “01” from the stationary.

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