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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)

Perineum: 1%

Right Leg: 18% (9% anterior and posterior)

Left Leg: 18% (9% anterior and posterior)

Total: 100%

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%

Perineum: 1%

Total: 68.5%

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.

– 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.

First Aid for Thermal Burns – Safety Basics

Thermal skin burns: how to assess the degree of damage

Statistically, most burns occur in domestic conditions and are caused by exposure to flame, boiling water, hot steam or incandescent objects. And – alas! – children often get them. That is why every adult should be guided in determining the degree of burns, since the choice of the method of first aid, the method of further treatment of the burn and the assessment of the need for medical (including inpatient) care depend on this.

So, due to the fact that in case of thermal burns (unlike chemical burns and eye burns) it is quite easy to determine their degree, each person should be able to do this. To begin with, if possible, clarify with the victim or others what happened, in order to make sure that the victim has a thermal burn, then examine the affected surface and assess the area of ​​the burn and the degree.

There are 4 degrees of burns:

1. First degree: redness and swelling of the skin at the site of a thermal burn. There may be small blisters with transparent contents.

2. Second degree: redness and swelling of the skin at the site of a thermal burn, as well as tense or broken blisters and a thin eschar that begins to form.

3. Third degree. In the third degree of thermal damage, there is a deep burn to the muscles and bones with the formation of a scab. Bubbles in the third degree, as a rule, have already burst. In this case, there may be small blisters with transparent contents around the deep burn zone (second degree burn), redness (first degree burn).

4. Fourth degree. At the fourth degree of a burn, charring of the burnt part of the body occurs. It is possible to combine the fourth degree with the first, second and third.

That is, one victim may have burns of varying degrees. In this case, the severity of the victim’s condition is assessed by the deepest burns, depending on the area of ​​the affected surface.

Thermal burns of the skin: how to estimate the area of ​​damage

Knowing how to determine the area of ​​a thermal burn is extremely important – this allows you to choose the right treatment tactics and sometimes even save the life of the victim. One of the simplest ways to estimate the area of ​​a burn is the “rule of the palm”. The area of ​​the palm of a person is on average 1% of the area of ​​his body. So, using the palm of your hand, you can determine how many percent of the body is affected.

There is also a 9% rule for adults: arm, half leg, half back, chest, stomach, head 9% each, and perineum 1%. But in children, the head with the neck makes up about 21% of the body area.

Thermal skin burns: how to choose the right first aid strategy .

In case of superficial thermal burns of more than 10% of the body area of ​​adults (in children – more than 5%) and with deeper burns from 5% of the body of an adult (respectively, more than 2. 5% of the body of a child), after first aid, mandatory medical assistance is required followed by hospitalization. Such burns lead to a violation of the general condition, threaten the life of the victim and may subsequently require surgical intervention.

In addition to these cases, victims with deep burns of the hands and feet and superficial extensive burns of the hands and feet, burns of the eyes, ears, face and perineum, as well as suspected burns of the respiratory tract due to inhalation of extremely hot air are subject to mandatory hospitalization .

Thermal skin burns: how to provide first aid

The algorithm for providing self-help and mutual assistance for any thermal skin burns is as follows: air), or throw off burning clothing. You can extinguish a flaming piece of clothing by throwing earth, sand or snow over it, dousing it with water, or lowering it into water.

– Reassure the victim and others.

– Carefully remove any smoldering clothing that has not stuck to the wound. It is forbidden to tear off the adhering remnants of clothing from the wound. It is also impossible to touch the burnt surface with your hands.

– In case of sunburn, simply move the victim into the shade.

– If you do not know what happened, briefly and quickly clarify the circumstances (“the child poured a cup of hot broth on himself”, “the clothes caught fire from the flames of a fire”).

– Keep the affected body surface under running cold water for 10-20 minutes (possibly in a container with clean cool water). This is necessary in order to prevent further deepening and expansion of the wound due to heating of the burnt area. It will also improve blood circulation in the wound. But in no case should ice be used to cool the burn area, since, in addition to the existing burn, the victim will have an additional injury – frostbite. In extreme cases (in the absence of running water), it is possible to cool the wound with urine, but in real life there is almost never a reason to use this method.

– Apply Solcoseryl® gel to the burnt surface, then apply a dry sterile dressing on top. In no case do not use cotton wool: you can only use a bandage, gauze – fabric materials. If there are no emergency burns nearby and sterile bandages are not available, you just need to apply a clean, dry bandage. It is forbidden to apply ointments, creams, vegetable oil, a beaten egg, sour cream, kefir, alcohol solutions and other means to the burned skin, as well as apply aloe leaves, Kalanchoe juice, golden mustache and others to the wound. For mild first-degree burns without extensive damage to the skin and blisters, you can not apply a bandage, but only apply the gel.

– In case of extensive burns of the arms and legs, fix the limb with a splint or improvised means and give the limb an elevated position.

– In case of extensive burns and if signs of burn shock occur (pallor, weakness, restlessness, cold sweat, tachycardia, drop in blood pressure, impaired cardiac activity and respiration), give the victim plenty of fluids to drink – clean water, tea, compote. The liquid reduces intoxication, which occurs due to the absorption of decay products of burned skin, subcutaneous tissue, and muscles into the blood.

– In severe pain, to prevent pain shock, the victim is given any painkiller (analgin, paracetamol, etc.).

– Start cardiopulmonary resuscitation (artificial respiration and chest compressions) in the absence of respiratory and (or) cardiac activity in the victim.

– In case of indications for hospitalization, call an ambulance or take the victim to a medical facility. It is still better to use the services of the “Ambulance”, since usually we do not know in which department of which hospital the treatment of burns is performed. If possible, this should be a specialized clinic or specialized department.

When can thermal skin burns be treated at home .

Not all burns require further treatment in a hospital or even a clinic. At home, you can independently treat superficial small burns without infection (without red swollen edges of the wound, without purulent discharge from the wound, fever, chills, increased pain in the wound, the appearance of twitching pain in the wound, etc. ).

Adults can start treating burns up to 1% of the body (the size of the person’s palm) at home, unless they are extensive burns to the hand, foot, face, genitals. This is important to know, as scarring can form during healing, which will impair the function of these parts of the body. Only non-infected burns to the hand, foot, or face (about the size of a coin) can be treated at home.

It should be remembered that in the case of a long-term non-healing burn, especially of the lower extremities with concomitant neurovascular pathology of the legs, deepening of the wound, the appearance of purulent discharge, an unpleasant odor from the wound, with increased pain and a violation of the general condition, it is necessary to contact the polyclinic surgeon .

Any burns in newborns require medical attention and usually hospital treatment.

If earth got into the wound during a burn, or the burn was received in nature, you should go to any emergency room or polyclinic surgeon on the same day to get vaccinated against tetanus, a dangerous infectious disease. It is good if the doctor also treats this burn surface. In the future, it will be possible to continue treatment at home.

What you need to prepare for the treatment of burns at home

– Sterile bandage – 1-2 packs per day (size and volume – depending on the area of ​​the burn).

– Hand sanitizer (antiseptic).

– Sterile medical gloves – 1 pair of gloves per dressing.

– Hydrogen peroxide (3% solution) – 1-2 vials per dressing.

– Alcohol solutions of iodine or brilliant green (the so-called “brilliant green”) – 1 bottle.

– Cotton swabs – 1 pack.

– Gauze swabs (for wound dressing) – you can make your own from a sterile bandage, wearing sterile gloves. Store them in a package from a sterile bandage. It is best to prepare new gauze pads before each dressing.

– Scissors.

– Plaster (sometimes necessary to secure the dressing to intact skin).

How to treat thermal skin burns at home

Attention! It is impossible to open burn blisters on your own and use cotton wool and plaster when treating the wound surface.