What is the rule of nines in burn assessment. How does it help medical professionals estimate burn severity. What are the limitations of using the rule of nines for burn evaluation. How does the rule of nines differ for children and adults.

Understanding the Rule of Nines: A Critical Tool in Burn Assessment

The rule of nines is a fundamental method used by medical professionals to quickly estimate the percentage of total body surface area (TBSA) affected by burns. This estimation is crucial for determining the severity of burn injuries and guiding appropriate treatment decisions. By dividing the body into sections, each representing a multiple of 9% of the total body surface area, healthcare providers can rapidly assess the extent of burn damage.

Key Body Sections in the Rule of Nines

• Head: 9%
• Each arm: 9%
• Each leg: 18%
• Front torso: 18%
• Back torso: 18%
• Genitalia: 1%

It’s important to note that these percentages can be further divided for more precise estimations. For instance, the front and back of an arm or the head would each represent 4.5% of the total body surface area.

The Significance of Burn Size Estimation in Medical Treatment

Accurate estimation of burn size is crucial for several reasons. First and foremost, it helps determine the severity of the burn injury, which directly influences the treatment approach. Additionally, burn size estimation guides fluid resuscitation protocols, which are essential for preventing shock and organ failure in severe burn cases.

How Does Burn Size Affect Treatment Decisions?

1. Fluid replacement therapy: The amount of fluid administered is often calculated based on the percentage of TBSA burned.
2. Hospitalization criteria: Burns covering more than 10-15% TBSA in adults or 5-10% in children often require hospitalization.
3. Wound care strategies: The extent of the burn influences the choice of dressings and topical treatments.
4. Nutritional support: Larger burns increase metabolic demands, necessitating specialized nutritional interventions.

Types of Burns: Understanding the Different Causes and Mechanisms

Burns can result from various sources, each with its unique characteristics and treatment considerations. Understanding the different types of burns is essential for proper assessment and management.

Thermal Burns: The Most Common Type

Thermal burns occur when the skin comes into contact with heat sources such as flames, hot liquids, or heated objects. These burns can vary in severity depending on the temperature and duration of exposure.

• Scalds from hot liquids or steam
• Contact burns from hot metals or other heated surfaces
• Flame burns from fires or explosions

Electrical Burns: A Hidden Danger

Electrical burns result from the passage of electrical current through the body. These burns can be particularly dangerous as they may cause internal damage that is not immediately visible on the skin surface.

• Direct contact with live electrical wires
• Lightning strikes
• Accidents involving faulty electrical equipment

Chemical Burns: When Substances Attack

Chemical burns occur when the skin or eyes come into contact with corrosive substances. These burns can continue to cause damage until the chemical is completely removed or neutralized.

• Industrial chemicals such as acids or alkalis
• Household cleaning products
• Mishandled laboratory substances

Burn Degrees: Assessing the Depth of Tissue Damage

Burns are classified into degrees based on the depth of tissue damage. Understanding these classifications is crucial for determining appropriate treatment strategies and predicting healing outcomes.

First-Degree Burns: Superficial Damage

First-degree burns affect only the outermost layer of skin, the epidermis. These burns are characterized by redness, mild swelling, and pain. They typically heal within a few days without scarring.

Second-Degree Burns: Partial-Thickness Injuries

Second-degree burns extend into the dermis, the second layer of skin. These burns are further classified into superficial partial-thickness and deep partial-thickness burns. They often result in blistering, severe pain, and potential scarring.

Third-Degree Burns: Full-Thickness Destruction

Third-degree burns destroy all layers of the skin and may extend into underlying tissues. These burns appear white, charred, or leathery and often require skin grafting for proper healing.

Fourth-Degree and Beyond: Severe Tissue Damage

Burns extending beyond the skin into subcutaneous fat (fourth-degree), muscle (fifth-degree), or bone (sixth-degree) are extremely severe and life-threatening. These burns require immediate and intensive medical intervention.

Applying the Rule of Nines in Burn Treatment: Practical Considerations

The rule of nines plays a crucial role in the initial assessment and management of burn patients. It guides critical decisions in the early stages of treatment, particularly in emergency settings.

Fluid Resuscitation: Calculating Needs Based on TBSA

One of the primary applications of the rule of nines is in determining fluid resuscitation requirements. The Parkland formula, a widely used method for calculating fluid needs in burn patients, relies on accurate TBSA estimation.

Parkland Formula: 4 mL × patient’s weight in kg × % TBSA burned = total fluid to be given in first 24 hours

Skin Grafting: Planning Based on Burn Extent

For extensive burns requiring skin grafting, the rule of nines helps surgeons estimate the amount of donor skin needed and plan the grafting procedure accordingly. This is particularly important in cases where large areas of the body are affected.

Limitations of the Rule of Nines: Understanding Its Constraints

While the rule of nines is a valuable tool, it’s important to recognize its limitations to ensure accurate assessment and appropriate treatment.

Variations in Body Proportions

The rule of nines is based on average adult body proportions. It may not be as accurate for individuals with significantly different body shapes, such as those who are obese or have unusually long limbs.

Challenges in Pediatric Burns

Children have different body proportions compared to adults, making the standard rule of nines less accurate. Modified versions, such as the Lund and Browder chart, are often used for pediatric burn assessment.

Irregular Burn Patterns

Burns often have irregular shapes and may cross multiple body regions, making it challenging to apply the rule of nines accurately. In such cases, more detailed assessment methods may be necessary.

Advanced Burn Assessment Techniques: Beyond the Rule of Nines

While the rule of nines remains a valuable tool, especially in emergency situations, more advanced techniques have been developed to improve the accuracy of burn size estimation.

3D Scanning Technology

Advanced 3D scanning systems can create detailed digital models of burn patients, allowing for more precise TBSA calculations. These technologies are particularly useful for complex burn patterns.

Computer-Assisted Planimetry

This technique involves tracing the burn area on a digital image of the patient’s body. Specialized software then calculates the exact TBSA affected, providing a more accurate assessment than visual estimation alone.

Bioelectrical Impedance Analysis

This non-invasive method measures the body’s electrical conductivity to estimate fluid shifts and tissue damage in burn patients. While not a direct replacement for TBSA estimation, it can provide valuable complementary information.

The Future of Burn Assessment: Innovations on the Horizon

As medical technology continues to advance, new methods for burn assessment and treatment are emerging. These innovations promise to enhance the accuracy of burn size estimation and improve patient outcomes.

Artificial Intelligence in Burn Assessment

Machine learning algorithms are being developed to analyze photographs of burns and provide rapid, accurate TBSA estimates. These AI-powered tools could potentially reduce human error and improve consistency in burn assessment.

Telemedicine Applications

Remote burn assessment tools are becoming increasingly sophisticated, allowing specialists to provide expert guidance in real-time to emergency responders or rural healthcare providers. These applications often incorporate advanced imaging and analysis capabilities.

Biomarkers for Burn Severity

Research is ongoing to identify blood-based biomarkers that can provide additional information about burn severity and prognosis. These markers could complement visual assessment methods and guide more personalized treatment approaches.

The rule of nines remains a cornerstone of burn assessment, providing a rapid and accessible method for estimating burn size in emergency situations. However, as our understanding of burn physiology deepens and technology advances, we can expect to see more sophisticated and accurate assessment tools emerge. These innovations will undoubtedly enhance our ability to provide optimal care for burn patients, improving outcomes and quality of life for those affected by these devastating injuries.

What Is It, and How Is It Used?

Written by WebMD Editorial Contributors

Medically Reviewed by Dan Brennan, MD on November 27, 2021

• Parts of the Rule of Nines
• Why Is the Rule of Nines Helpful?
• Types of Burns
• The Rule of Nines in Burn Treatment
• Limits of the Rule of Nines

The rule of nines is a tool used to estimate a burn’s percentage of your total skin. It divides your body into sections by multiples of 9% each.

The sections in the rule of nines are:

• Head: 9% 
• Genitalia: 1%
• Arm: 9%
• Leg: 18% 
• Torso: 36%‌

The body sections can divide in half. For example, the front side of one arm or your head is 4.5% of your total body surface area. The front and back of your torso are 18% each. ‌

These percentages are accurate for people over age 14.

The rule of nines gives an idea of how much of your total body’s surface area a burn takes up. This informs treatments based on the size and intensity of the burn injury.

Emergency medical responders are some of the medical workers who use the rule of nines most. They quickly estimate the burn area to decide on treatments on the way to the hospital. 

The rule of nines applies to burns from all causes. The most common causes of burn injuries are:

Thermal.Thermal burns result from contact with a hot surface, object, or flames. The heat kills your skin cells. Common causes of thermal burns include:

• Steam 
• Boiling liquids
• Hot metals 
• Fires‌

Electrical. Electrical burns come from direct contact with an electrical current. Electrical currents are high amounts of energy that flow through wires. Accidents that cause electrical burns include:

• Touching exposed wires
• Using faulty machinery or electrical equipment
• Touching a power line or pole
• Touching an electrical device that water is touching, such as a hair dryer in the sink while it’s still plugged in
• Lightning

Electrical burns can damage other areas besides your skin. Electric shock can weaken your muscles, impact your vision, or in severe cases stop your heart. 

Chemical. Chemical burns come from contact with harsh or dangerous chemicals. These chemicals can cause damage similar to thermal burns. Chemicals that can burn your skin include:

• Drain cleaners
• Wet cement
• Bleach
• Battery acid‌

Your skin has multiple layers between its surface and underlying tissues like muscle and fat. Burns have degrees based on how deep they reach into your skin.

First-degree. First-degree burns affect only the top layer of skin (called the epidermis). They can cause redness, skin dryness, and pain. First-degree burns usually heal with no scarring. ‌

The rule of nines usually isn’t needed in first-degree burn care.‌

Second-degree. Second-degree (or partial-thickness) burns reach the deeper layers of your skin (called the dermis). They often swell and blister. Second-degree burns can leave permanent scars.‌

Third-degree. Third-degree (or full-thickness) burns reach to the deepest part of your skin and parts below the skin, like hair roots and sweat glands. ‌

Fourth-degree burns reach underlying fat. Fifth-degree burns reach muscle. Sixth-degree burns reach bone.

Burn injuries can seriously damage your skin and other parts of your body. Your immune system’s response to a severe burn can lead to shock, heart failure, and organ damage.

Medical providers need to know a burn’s relative size using the rule of nines to decide on treatments. 

Burn treatments include:

Skin grafts. Skin grafting is a treatment that takes healthy skin from one part of your body and places it on an injured area. This helps protect the injury from infection. 

Determining a burn injury’s total body surface area using the rule of nines can help doctors plan a skin graft treatment.

Fluid replacement. Severe burns can cause your body to lose too much fluid, like blood, sweat, and water, inside your cells. This means you may need a fluid IV to keep enough water inside your body. ‌

A burn’s amount of total body surface area informs how much water should go in your IV line.

Human error. Burns can spread over your body so they are unevenly distributed across the rule of nines’ sections. A burn injury’s size, shape, and depth can make it hard to guess its percentage of total body surface area. ‌

Inaccurate guesses can cause doctors to use too much fluid or too little fluid in treatment. This can lead to kidney problems, liver damage, swelling, and other issues.‌

Different body sizes. The rule of nines doesn’t apply to children or patients who are obese. Babies and children under 14 have different rules for estimating a burn’s percentage of total body surface area.  ‌

Many other rules for estimating a burn’s size can apply to patients who are obese. Based on their body shapes, different body parts have different percentages of total body surface area.

Top Picks

What Is It, and How Is It Used?

Written by WebMD Editorial Contributors

Medically Reviewed by Dan Brennan, MD on November 27, 2021

• Parts of the Rule of Nines
• Why Is the Rule of Nines Helpful?
• Types of Burns
• The Rule of Nines in Burn Treatment
• Limits of the Rule of Nines

The rule of nines is a tool used to estimate a burn’s percentage of your total skin. It divides your body into sections by multiples of 9% each.

The sections in the rule of nines are:

• Head: 9% 
• Genitalia: 1%
• Arm: 9%
• Leg: 18% 
• Torso: 36%‌

The body sections can divide in half. For example, the front side of one arm or your head is 4.5% of your total body surface area. The front and back of your torso are 18% each. ‌

These percentages are accurate for people over age 14.

The rule of nines gives an idea of how much of your total body’s surface area a burn takes up. This informs treatments based on the size and intensity of the burn injury.

Emergency medical responders are some of the medical workers who use the rule of nines most. They quickly estimate the burn area to decide on treatments on the way to the hospital. 

The rule of nines applies to burns from all causes. The most common causes of burn injuries are:

Thermal.Thermal burns result from contact with a hot surface, object, or flames. The heat kills your skin cells. Common causes of thermal burns include:

• Steam 
• Boiling liquids
• Hot metals 
• Fires‌

Electrical. Electrical burns come from direct contact with an electrical current. Electrical currents are high amounts of energy that flow through wires. Accidents that cause electrical burns include:

• Touching exposed wires
• Using faulty machinery or electrical equipment
• Touching a power line or pole
• Touching an electrical device that water is touching, such as a hair dryer in the sink while it’s still plugged in
• Lightning

Electrical burns can damage other areas besides your skin. Electric shock can weaken your muscles, impact your vision, or in severe cases stop your heart. 

Chemical. Chemical burns come from contact with harsh or dangerous chemicals. These chemicals can cause damage similar to thermal burns. Chemicals that can burn your skin include:

• Drain cleaners
• Wet cement
• Bleach
• Battery acid‌

Your skin has multiple layers between its surface and underlying tissues like muscle and fat. Burns have degrees based on how deep they reach into your skin.

First-degree. First-degree burns affect only the top layer of skin (called the epidermis). They can cause redness, skin dryness, and pain. First-degree burns usually heal with no scarring. ‌

The rule of nines usually isn’t needed in first-degree burn care.‌

Second-degree. Second-degree (or partial-thickness) burns reach the deeper layers of your skin (called the dermis). They often swell and blister. Second-degree burns can leave permanent scars.‌

Third-degree. Third-degree (or full-thickness) burns reach to the deepest part of your skin and parts below the skin, like hair roots and sweat glands. ‌

Fourth-degree burns reach underlying fat. Fifth-degree burns reach muscle. Sixth-degree burns reach bone.

Burn injuries can seriously damage your skin and other parts of your body. Your immune system’s response to a severe burn can lead to shock, heart failure, and organ damage.

Medical providers need to know a burn’s relative size using the rule of nines to decide on treatments. 

Burn treatments include:

Skin grafts. Skin grafting is a treatment that takes healthy skin from one part of your body and places it on an injured area. This helps protect the injury from infection. 

Determining a burn injury’s total body surface area using the rule of nines can help doctors plan a skin graft treatment.

Fluid replacement. Severe burns can cause your body to lose too much fluid, like blood, sweat, and water, inside your cells. This means you may need a fluid IV to keep enough water inside your body. ‌

A burn’s amount of total body surface area informs how much water should go in your IV line.

Human error. Burns can spread over your body so they are unevenly distributed across the rule of nines’ sections. A burn injury’s size, shape, and depth can make it hard to guess its percentage of total body surface area. ‌

Inaccurate guesses can cause doctors to use too much fluid or too little fluid in treatment. This can lead to kidney problems, liver damage, swelling, and other issues.‌

Different body sizes. The rule of nines doesn’t apply to children or patients who are obese. Babies and children under 14 have different rules for estimating a burn’s percentage of total body surface area. ‌

Many other rules for estimating a burn’s size can apply to patients who are obese. Based on their body shapes, different body parts have different percentages of total body surface area.

Top Picks

Rule of Nine

I like to work and I don’t like to relax.

In my senior years I worked sixteen to eighteen hours a day. Sleepless nights were common. Once a month I could work for a whole day and a little more – my head was still thinking, and then I could always sleep off. At such moments, I considered myself a hero of labor: everyone is sleeping, drinking and having fun, and I alone heroically climb the mountain.

Here’s what I learned about heroic work

The degree of heroism is in no way connected with the benefit that you bring, neither for yourself nor for those around you. The way you push yourself has little to do with the value you bring with your work.

People don’t give a damn how hard you work. The client does not need heroism, but a good result. How you get to this result depends much more on professionalism than on perseverance.

Sitting on tasks at night is a sign of an amateur. The amateur does not manage himself and his time well, negotiates badly, makes unnecessary promises, does not delegate tasks, gets distracted, procrastinates, spends too much time on insignificant things. A professional not only does his job well, but also manages to do it on time.

The professionals I look up to have severe limitations in their work. One of them starts the working day at 14:00. The other does not work on weekends. The third never does things on the same day they appear – he has the principle “Do it tomorrow”. I feel uncomfortable conforming to these restrictions, but I respect them. They are also respected by other people.

Heroism is a shortcoming

Unfortunately, I myself did not set any limits for myself. Therefore, he heroically worked on weekends, and on weekdays, and early in the morning, and late at night. And if you look back at all the work done, the most valuable and useful of what I did was done outside of this heroic work. Everything that was done urgently and overtime was usually not needed by anyone.

When I started thinking about it, I saw that there is nothing good in heroism. Sitting at night and bending to every request of a client is the path of a student, not a professional. Requests and comments will not decrease. There will be no less work. If nothing changes, I will forever remain a bearded, hunched-over editor at a computer at four in the morning.

To use the mountain metaphor, I am climbing a mountain without equipment. And the point is not to climb, but to move up. Both a helicopter and a lift are suitable for this. In order to become a professional and be more useful, I must build myself a helicopter.

So I start the experiment. From July 25, 2014, I introduce the “Rule of Nine”.

Rule of Nine

From Monday to Friday, work starts at nine in the morning and ends at nine in the evening. There is no work from nine in the evening until nine in the morning. There is no work on weekends.

Consequences of the rule of nine:

All work is planned from nine in the morning to nine in the evening. I take responsibility for the fact that I will fulfill all my promises for the day before nine in the evening.

No “tails” are closed after nine in the evening. If I understand that I am not on time for something, I go to the client and re-negotiate.

Any meeting, call or Skype ends at 9 pm, regardless of their phase and stage. This means that any meeting should begin no later than half past seven.

The Rule of Nine does not apply to courses, trainings and public speaking – mine or other people’s. I can break the rule of nine if I’m teaching or participating in someone else’s course, hosting Living Advice, or giving a public lecture.

The Rule of Nine can be a barrier to collaboration. For example, if your working day starts at 6 pm Moscow time, and the active phase falls at 3 am, then we will not dock. If this is an insurmountable obstacle for you, then we should not cooperate, even if we are perfect for each other.

P. S. For greater effect, I will consider buying a light and thin laptop that confidently holds a charge for 12 hours at full screen brightness. I heard that new macbooks can do this, but I don’t believe it. Connoisseurs, advise, please.

The 9-thing rule: a way to do everything

How often have you taken on several tasks at the same time, but in the end did not have time to do anything worthwhile for the whole day? At such moments, we usually dream of finding at least a couple of extra hours in the day and finding a way to be more productive and not burn out. Together with an expert, we analyze a simple but effective technique that will help you distribute the load and achieve all your goals for the day!

Tags:

Life style

time management

You must have wondered: “Why do people around me somehow magically manage to do everything, and I almost nothing?” If you are familiar with this problem, then our material will come in handy. Especially for VOICE readers, the psychologist spoke about the tricky technique “9 things to do”, which will help in proper planning of the day and will not let you drive yourself into stress. Try to follow these tips, and very soon you will notice that almost everything is subject to you!

Elena Milto

Candidate of Psychological Sciences, promoter of the psychology of effectiveness and author of the method of sheff_thinking

There is a lot of information around, the flow of the desired is outlined, but, alas, there is not enough competence for everything. Hence the broken biorhythms, stress, burnout and other “charms” of the modern world. This can lead to apathy, fear and increased levels of anxiety. To avoid this, it is enough to apply a prophylactic from the arsenal of sheff_thinking.

The right “pill” here is, first of all, the ability to plan correctly. The vertical of effective planning is built in turn: hour, day, week.

The simplest and most effective way of prevention is the “9 things” technique. I use it myself and also often recommend it to our sorority members who are facing time constraints. So the formula is simple: 9=1+3+5. And now we understand in detail!

Nine tasks is the maximum that we promise ourselves to accomplish in a day: there are both large and small tasks among them. To begin with, we choose one of the largest and most urgent things – it will be the main and mandatory one. Next, we single out three tasks of “medium severity” and five more tasks that do not require a lot of effort, time and energy for implementation.

ADVERTISING – CONTINUED BELOW

Let’s analyze the formula using a simple example from my life:

• +1: I will write one chapter of my book, which is resource-intensive for me;
• +3: I will zoom with a colleague + set tasks for employees + make a birthday itinerary – these tasks are time-consuming, but not paramount;
• +5: I will sign the child up to the doctor + I will put the dishes in the dishwasher + I will publish a post on Instagram (The social network is recognized as extremist and banned on the territory of the Russian Federation) + I will order groceries at home + I will pay the bills.