Rule of nines picture: Burn Percentage in Adults: Rule of Nines Chart
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.).
- Burn triage and treatment – Thermal injuries. (2017).
- Helttiaratchy S. (2004). Initial management of a major burn: II—assessment and resuscitation. DOI:
- Lee KC, et al. (2014). History of burns: The past, present and the future. DOI:
- Quick reference guide: Burn stabilization. (n.d.).
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Medically reviewed by Alana Biggers, M.D., MPH — By Rachel Nall, MSN, CRNA — Updated on July 20, 2018
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Rule of Nines for Burns in an Adult NCLEX Review
This NCLEX review will discuss the Rule of Nines for burns in an adult patient.
If you’re studying burns right now in class, you can probably count on a rule of nines burn question being on your exam. It’s a popular topic to cover on a burns exam.
Lecture on Rule of Nines
What is the Rule of Nines?
It’s a quick calculation that can be used to calculate the total body surface area (TBSA) percentage that is burned on a patient. It is used for burns that are at least partial-thickness or greater.
- Why do we need to know the total body surface area percentage burned on a patient?
It tells us the severity of the burn. For example, does this patient need specialized care and meet the criteria for a burn unit? Another reason, which is a BIG one, this percentage will determine the fluid replacement treatment regime.
When a patient experiences about 15% or more of a total body surface area that is burned there is a major change in capillary permeability and the patient most definitely needs fluid replacement (Diver, 2008).
- What happens during a severe burn to the capillary permeability?
When a patient experiences a major burn, there is a shift of fluid from the intravascular area to the interstitial tissues (so fluid leaves the blood), and this is due to an increase in capillary permeability. Because of this shift there will be barely anything left in the circulation for the heart to pump to vital organs…without blood they start to die. So, a patient is at risk for hypovolemic shock when they experience severe burns.
Lactated Ringer’s (an isotonic solution) is most commonly used to help expand the intravascular compartment. To determine how much fluid a patient will need 24 hours after a severe burn, the Parkland Burn Formula is used (please see the next review for how to calculate the amount of fluid a patient needs after a severe burn).
Rule of Nines for Burns
Now, let’s look at the Rule of Nines!
Each area of the body is broken down by nines (hence makes it easier to remember). I like to start my way from the top and work downward:
NOTE: Remember that there is a FRONT AND BACK percentage value assigned to EACH AREA (many people forget this and get their calculation wrong).
Head and Neck: 9% (4.5% anterior and posterior)
Right Arm: 9% (4.5% anterior and posterior)
Left Arm: 9% (4.5% anterior and posterior)
Trunk: 36% (18% anterior and posterior)
Right Leg: 18% (9% anterior and posterior)
Left Leg: 18% (9% anterior and posterior)
Rule of Nines Practice Problem:
A 35 year old female patient has deep partial-thickness burns on the front and back of both arms, anterior trunk, back of left leg, anterior and posterior sides of the right leg, posterior head and neck, and perineum. What is the total body surface area percentage that is burned?
FRONT and BACK of both arms: 18%
ANTERIOR trunk: 18%
BACK of left leg: 9%
ANTERIOR and POSTERIOR of right leg: 18%
POSTERIOR head and neck: 4.5%
More Rule of Nines Practice Problems
Burn Triage and Treatment: Thermal Injuries – Radiation Emergency Medical Management. (2018). Remm.nlm.gov. Retrieved 27 March 2018, from https://www.remm.nlm.gov/burns.htm
Diver, A. (2008). The evolution of burn fluid resuscitation. International Journal Of Surgery, 6(4), 347. Retrieved from https://www.sciencedirect.com/science/article/pii/S1743919108000290
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.
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.
Thermal burn: first aid treatment
Causes of thermal burns
- exposure to open fire on the skin or as a result of ignition of clothing
- contact with hot metal, sintered objects or other objects (iron, frying pan, hob, asphalt spray, etc.)
- reaction to electrical damage to the body
- exposure to the sun (sunburn)
90 061 exposure hot liquid or vapor
Severity of thermal burns. Main symptoms
Thermal burn injuries are: I, II, III and IV degrees .
1st degree burns
1st degree burns are called superficial , or epidermal 1 . Only the top layer of the skin is damaged. Symptoms will be swelling, soreness or burning, red color of the skin. These burns can be treated on their own. As a rule, it is possible to restore the skin in a few days. After healing, the damaged area of the skin will not differ in color from the rest of the skin, but temporary peeling may be present. 9. The damaging effect affects the deeper layers of the skin. Therefore, with such burns, along with reddening of the skin, swelling and pain, blisters with transparent contents form. Healing occurs within two weeks. Often, after complete skin repair, the damaged area will be either a darker or lighter shade compared to unaltered skin.
3rd degree burns
3rd degree burns called deep 1 . The burn process involves all layers of the skin, including subcutaneous fatty tissue.
Structure of the skin
In this case, the symptoms, depending on the cause of the thermal burn, will vary. So, upon contact with an open fire or a hot object, a crust (scab) of a brownish color forms on the surface, and when the skin is scalded with hot liquid or steam, it is wet, white-gray.
Blisters may also form in deep burns.
Recovery of burn injuries takes up to 1.5 months. Skin grafting is often required. Upon healing, a violation of skin pigmentation remains, well-marked scars are formed.
IV degree burns
Burns IV degree not only kill the skin and membranes covering the muscles (fascia), muscles and bones can also be affected 2 . A dark crust and areas of charring appear. Recovery is extremely slow, as a rule, surgical treatment, skin grafting is required. The issue of saving the affected parts of the body is being resolved.
Determining the area of a thermal burn. Injury severity index (ITI)
In most cases, a doctor can diagnose a thermal burn already during a visual examination. If the person is conscious, you can ask about what happened and clarify the specific cause of the thermal burn.
To select the tactics of treatment of burn wounds, it is necessary to diagnose the severity of the burn injury.
In combustiology, a branch of medicine dealing with the study of burns, to determine the burn area use the “rule of the palm” and the “rule of nines”.
“Rule of the palm”
The area of one palm of the patient is 1% of the entire body surface 2 . This rule is suitable for determining non-extensive burn injuries.
“Rule of nines”
In an adult, the area of the skin of the head is 9% of the area of the whole body. Upper limb – 9%, one lower limb – 18%, Front and back surface of the body – 18% each, genitals
and perineum – 1% 2 .
Injury severity index
For a special assessment of the damage area, the injury severity index (ITI) is calculated. This indicator is based on an assessment of the depth and extent of the lesion and is expressed in conventional units.
- With burns of I-II degrees, 1% of the burn area is equal to 1 unit.
- For IIIa degree burns, 1% of the burn area is equal to 2 units.
- In case of IIIb-IV degree burns, 1% of the burn area is equal to 3 units.
Complications of burns
A serious complication of thermal burns is burn shock 2
- pressure drop
- decrease or cessation of urine production by the kidneys (oliguria and anuria)
- chills and palpitations
- pallor and dryness of the skin
- motor excitation
Light shock develops with a deep burn of no more than 20% of the body surface, ITP 30-70 units.
Severe shock – with a burn of 20-40% of the body surface, ITP 71-130 units.
Extremely severe shock – burned more than 40% of the body surface,
ITP more than 130 units.
The shock period lasts from 10 hours to 3 days, depending on the severity of the shock.
From the 4th to the 14th day, due to the general effect on the body of the decay products of dead tissues and bacteria, acute burn toxemia occurs .
Burn shock is treated in a hospital, where adequate anesthesia is performed, bladder catheterization is carried out, and water and electrolyte balance is corrected. Artificial ventilation is often required.
Local complications of thermal burns include infection with bacteria and fungi, loss of function of the affected body part, severe scarring and contractures.
Treatment of thermal burns
Most household thermal burns, given their small size and mild severity, do not require medical attention.
However, it is important to provide correct first aid.
First aid for thermal burns
- Stop contact with heat as soon as possible or extinguish burning clothing with water or a blanket.
- Cool the area of thermal burn with cold water, ice, snow, cooling packs. This will allow to lower the temperature inside the tissues and reduce the damaging effects of heat.
- The burnt part of the body is cut and removed. Adhering clothes are not torn off.
- Formed blisters should not be pierced. You can use a sterile needle from a sterile syringe if the bubble is single and small. With multiple blisters, you need to seek medical help.
Ointments and creams for burns
What are the types of ointments for the treatment of burns, and how to choose the most effective one.
Treatment of light superficial burns
In the treatment of first degree burns, soothing creams, aerosols, solutions containing panthenol, dexpanthenol, tannin are used. Changes in the lesion are completely reversible and healing occurs within a few days.
Treatment of II-III degree burns
The formation of blisters indicates a violation of the integrity of the skin, and necrosis of the skin or other tissues of the body is a predisposing factor for the development of infection. Therefore, burns of the second or more severe degrees are susceptible to infection by pathogens .
To prevent the development of purulent complications, proper care and treatment of the burn surface is important, both before seeking medical help and after medical intervention.
A fresh burn wound surface must be washed in order to decontaminate and mechanically remove foreign particles and microorganisms. Usually, solutions of furacilin, potassium permanganate, chlorhexidine are used. Then a 5% iodine solution is applied along the edges of the wound. Moreover, it should be noted that there are special forms of iodine, which are called povidone-iodine.
Treatment of thermal burns with preparations based on povidone-iodine (Betadine®)
For disinfection of the wound surface, it is recommended to use solution of povidone-iodine ( Betadine ® ), which, unlike the above antiseptics, does not contain alcohol, approved for use on the entire surface of the burn, does not cause burning of injured tissues.
Povidone-iodine ( Betadine ® ) contributes to the death of bacteria, fungi, protozoan unicellular microorganisms, viruses 3 . At the same time, the drug is practically not absorbed into the bloodstream 3 , which indicates a high safety profile.
Antiseptic, disinfectant ointment Betadine ® can be used to treat burns. The agent is applied to the burn surface 2-3 times a day with a thin layer. In the treatment of burns Betadine ® ointment can be left under the dressing. In the treatment of infected wounds under wipes soaked in a solution or ointment Betadine ® , during the first 5-7 days the edema and the amount of purulent discharge decreased, there was a decrease in pain 4 . The use of Betadine ® solution or ointment is permitted in adults and children from the age of 3 .
Where can I buy Betadine® solution?
Find the nearest pharmacy0003
Iodine-based ointment: mechanism of action, scope. Ointment Betadine® based on povidone-iodine for the treatment of various skin diseases.
Treatment of thermal burns at the stage of healing and maturation of the scar
Along with antiseptic therapy, external healing agents based on lanthanum salts, sodium deoxyribonucleate can be used. In some complicated cases, antibiotic treatment may be required. After healing, for the preventive and therapeutic purpose of developing rough scars, preparations based on silicone, hyaluronidase, and glucocorticosteroids are prescribed.
Burn Injury Prevention
- Small children should not be left alone.
- Use protective covers for sockets.
- Install thermostats on the water pipes.
- Install protective screens on radiators.
- Mugs, plates, pots, pans with hot contents should be placed closer to the center of the table or on the far burners of the hob.
- Keep matches and lighters out of the reach of children.
- Electrical appliances placed on countertops should be moved closer to the wall – away from the water source.
- Observe safe tanning practices. Stay in the open sun until 11.00 and after 16.00. Use sunscreen with at least 30 SPF.
Frequently Asked Questions
When should I seek medical attention for a thermal burn?
Urgently call an ambulance if:
- burn area over 5% (5 palms) of body surface
- burn of 3-4 degrees
- smoke inhalation occurred, airways burned
- burns of the face or neck, inguinal region, two limbs burned
- burn injury occurred a eye
- a child or an elderly person received a thermal injury
If purulent complications appear during the treatment of even small burns, a doctor’s consultation is necessary.
Is it possible to wet the skin after a burn?
Immediately after a thermal injury, it is even recommended to cool the skin with pure cold water. If a burn of 1 and 2 degrees – hold under running water for 10-15 minutes. If the burn is 3 and 4 degrees, use a clean, damp bandage to cool the damaged area of the skin. When cooling injured skin with water, do not rub or try to actively clean the wound.
It should be noted that during the healing period of burns, characterized by damage to the integrity of the skin, it is not recommended to contact with water, visit a sauna, bath, pool.
Can I bandage burnt skin?
Bandaging or a clean dressing is recommended for initial pre-hospital treatment of thermal burns and during the healing period. In this case, cotton wool or other pile materials should not be used.
Moshkova Elena Mikhailovna
Dermatovenereologist, Head of the CDO for the provision of paid services, St. Petersburg State Budgetary Institution of Healthcare “City Dermatovenerologic Dispensary”, St. Petersburg
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Wounds with infection
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What are iodine solutions and what are they used for?
Ointments and creams for burns
What are the ointments for the treatment of burns, and how to choose the most effective one.
- Clinical recommendations “Thermal, chemical burns. Sun burns. Respiratory tract burns, 2020.
- Mikhailovich V.A., Miroshnichenko A.G. “Guidelines for emergency physicians”, 4th edition, 2007.
- Instructions for medical use of the drug Betadine®, solution, RU P N015282/03.
- Mikhalsky V. V., Bogdanov A. E., Zhilina S. V., Prvidentsev A. I., Anikin A. I., Ulyanina A. A. “The use of the drug in the treatment of infected wounds”.