What is the rule of nines. How does it help in estimating burn severity. Why is accurate burn assessment critical for proper treatment. What are the limitations of the rule of nines.

Understanding the Rule of Nines: A Vital Technique in Burn Assessment

The rule of nines is a critical tool used by medical professionals to quickly estimate the percentage of a person’s total body surface area (TBSA) affected by burns. This estimation method divides the body into sections, each representing a multiple of 9% of the total body surface area. By understanding this technique, healthcare providers can make rapid assessments and crucial treatment decisions in burn cases.

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 subdivided. For instance, the front of an arm or the face alone would account for 4.5% of the TBSA. This level of detail allows for more precise assessments, especially in cases where burns are not uniformly distributed across the body.

The Significance of Burn Size Estimation in Medical Treatment

Accurate estimation of burn size is crucial for determining appropriate treatment strategies. Why is this so important? The extent of a burn injury directly impacts the body’s physiological response and the potential complications that may arise. Knowing the percentage of TBSA affected helps medical professionals make informed decisions about fluid resuscitation, wound care, and potential surgical interventions.

How Does Burn Size Affect Treatment Decisions?

1. Fluid Resuscitation: Larger burns require more aggressive fluid replacement to prevent shock and organ damage.
2. Wound Care: The size of the burn influences the choice of dressings and topical treatments.
3. Surgical Planning: For extensive burns, skin grafting may be necessary, and the size of the burn helps determine the amount of donor skin required.
4. Nutritional Support: Larger burns increase metabolic demands, necessitating tailored nutritional interventions.

Types of Burns: Understanding the Different Causes and Their Implications

Burns can result from various sources, each presenting unique challenges in assessment and treatment. The rule of nines is applicable regardless of the burn cause, but understanding the different types can provide valuable context for medical professionals.

Thermal Burns

Thermal burns are the most common type, resulting from contact with hot surfaces, objects, or flames. These burns occur when heat causes direct damage to skin cells. Common sources of thermal burns include:

• Steam
• Boiling liquids
• Hot metals
• Open flames

Electrical Burns

Electrical burns occur when an electric current passes through the body. These burns can be particularly dangerous as they may cause internal damage not immediately visible on the skin surface. Causes of electrical burns include:

• Contact with exposed wires
• Faulty electrical equipment
• Lightning strikes
• Accidental contact with power lines

Electrical burns require special attention as they can affect deep tissues, muscles, and even internal organs. The rule of nines may not fully capture the extent of damage in these cases, necessitating additional diagnostic measures.

Chemical Burns

Chemical burns result from contact with corrosive substances. These burns can continue to cause damage until the chemical is completely removed from the skin. Common causes include:

• Industrial chemicals
• Household cleaning products
• Strong acids or bases
• Cement

When assessing chemical burns using the rule of nines, it’s crucial to consider that the visible skin damage may not accurately represent the full extent of the injury, as some chemicals can penetrate deeply into tissues.

Degrees of Burns: From Superficial to Life-Threatening

Burns are classified into degrees based on the depth of tissue damage. Understanding these classifications is essential for proper treatment and prognosis. How do different degrees of burns impact the application of the rule of nines?

First-Degree Burns

First-degree burns affect only the outermost layer of skin (epidermis). They typically present as redness, mild swelling, and pain. While these burns are included in the rule of nines assessment, they generally don’t require extensive medical intervention.

Second-Degree Burns

Second-degree burns, also known as partial-thickness burns, extend into the dermis. They often result in blistering, severe pain, and potential scarring. The rule of nines is particularly useful in assessing these burns, as their extent significantly impacts treatment decisions.

Third-Degree Burns and Beyond

Third-degree burns, or full-thickness burns, destroy all layers of skin and can damage underlying tissues. Fourth, fifth, and sixth-degree burns involve progressively deeper structures, including fat, muscle, and bone. In these severe cases, the rule of nines is crucial for initial assessment, but additional diagnostic tools may be necessary to fully evaluate the extent of damage.

Applying the Rule of Nines in Emergency Burn Care

The rule of nines is particularly valuable in emergency settings, where rapid assessment and decision-making are critical. Emergency medical responders often use this method to quickly estimate burn size and severity while en route to the hospital. How does this initial assessment impact immediate care and hospital preparation?

Immediate Care Decisions

• Fluid Resuscitation: The estimated burn size helps determine the volume of IV fluids needed to prevent shock.
• Pain Management: Larger burns may require more aggressive pain control measures.
• Airway Management: Extensive burns, especially those involving the face or neck, may necessitate early intubation.

Hospital Preparation

The initial assessment using the rule of nines allows emergency departments to prepare appropriate resources before the patient arrives. This may include:

• Alerting burn specialists
• Preparing operating rooms for potential debridement or grafting procedures
• Ensuring adequate supplies of wound dressings and medications

Advanced Burn Treatments Guided by the Rule of Nines

The rule of nines plays a crucial role in determining the course of advanced burn treatments. How do these estimations influence complex medical interventions?

Skin Grafting

For extensive burns, skin grafting is often necessary to promote healing and prevent infection. The rule of nines helps surgeons estimate the amount of donor skin required and plan the grafting procedure. In cases where the available donor skin is limited, knowing the exact percentage of burned area allows for prioritization of treatment areas.

Fluid Replacement Therapy

Severe burns can lead to significant fluid loss, requiring carefully calculated fluid replacement. The Parkland formula, commonly used for fluid resuscitation in burn patients, relies on the percentage of TBSA burned as determined by the rule of nines. This formula helps prevent complications such as hypovolemic shock and organ failure.

Nutritional Support

Extensive burns increase the body’s metabolic rate, necessitating tailored nutritional support. The percentage of TBSA burned, as estimated by the rule of nines, helps dietitians and clinicians calculate the increased caloric and protein requirements for optimal healing.

Limitations and Considerations in Using the Rule of Nines

While the rule of nines is a valuable tool, it’s important to recognize its limitations and potential sources of error. What factors can affect the accuracy of burn size estimation using this method?

Body Size and Age Variations

The standard rule of nines is most accurate for adults with average body proportions. It requires modification for:

• Children: Their proportionally larger heads and smaller limbs necessitate different percentage allocations.
• Obese individuals: Altered body proportions can lead to overestimation of burn size in certain areas.
• Very thin individuals: Similar to obesity, extreme thinness can affect the accuracy of estimations.

Irregular Burn Patterns

Burns often have irregular shapes and distributions that don’t neatly align with the body sections outlined in the rule of nines. This can lead to overestimation or underestimation of the affected area, potentially impacting treatment decisions.

Depth Considerations

The rule of nines focuses on surface area and doesn’t account for burn depth. In cases of mixed-depth burns or burns that appear superficial but have deeper damage (as with some electrical or chemical burns), additional assessment methods are necessary.

Human Error

Even experienced practitioners can make errors in visual estimation. Factors such as lighting conditions, patient positioning, and time pressure in emergency situations can all contribute to inaccuracies.

To mitigate these limitations, healthcare providers often use the rule of nines in conjunction with other assessment tools and technologies, such as digital imaging and computerized mapping of burn areas. This multi-faceted approach helps ensure more accurate burn size estimation and, consequently, more appropriate treatment planning.

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.