What is the Rule of Nines. How is it used in burn assessment. Why is accurate burn surface area estimation crucial. When should the Rule of Nines be modified. How does obesity affect burn area calculations. What adaptations are necessary for pediatric patients.

Understanding the Rule of Nines: A Cornerstone of Burn Assessment

The Rule of Nines, also known as the Wallace Rule of Nines, is a critical tool in the arsenal of trauma and emergency medicine providers. Its primary function is to quickly and accurately assess the total body surface area (TBSA) affected by burns in patients. This assessment is crucial for determining the severity of burns and calculating the necessary fluid resuscitation requirements.

But why is this rule called the “Rule of Nines”? The name stems from the way it divides the body into sections, each representing approximately 9% (or multiples of 9%) of the total body surface area. This simple yet effective system allows for rapid estimation of burn extent, which is vital in the critical early stages of burn management.

Breaking Down the Body Percentages

• Head: 9% (4.5% anterior, 4.5% posterior)
• Entire trunk: 36% (18% anterior, 18% posterior)
• Each upper extremity: 9% (18% total for both arms)
• Each lower extremity: 18% (36% total for both legs)
• Groin: 1%

It’s important to note that the Rule of Nines is specifically used for assessing second-degree and third-degree burns, also known as partial thickness and full thickness burns respectively. First-degree burns are not included in this calculation as they do not significantly impact fluid requirements or overall burn severity.

The Crucial Role of TBSA in Burn Management

Why is determining the total body surface area affected by burns so important? The answer lies in the body’s physiological response to severe burns. When a significant portion of the skin is damaged, it leads to massive fluid losses due to the compromised skin barrier. This fluid loss can quickly lead to hypovolemic shock if not addressed promptly and adequately.

Accurate TBSA estimation allows healthcare providers to:

1. Determine the severity of the burn injury
2. Calculate appropriate fluid resuscitation volumes
3. Predict potential complications and outcomes
4. Guide overall treatment strategies

For burns covering more than 20% TBSA, immediate and aggressive fluid resuscitation is crucial to prevent complications such as renal failure, myoglobinuria, hemoglobinuria, and multi-organ failure. Studies have shown that mortality rates are significantly higher in patients with burns exceeding 20% TBSA who do not receive appropriate fluid resuscitation immediately following the injury.

Fluid Resuscitation: Applying the Rule of Nines

Once the TBSA has been determined using the Rule of Nines, how do healthcare providers use this information to guide fluid resuscitation? The most commonly used method is the Parkland formula, which calculates the total fluid requirement for the first 24 hours post-burn.

The Parkland Formula

The Parkland formula is calculated as follows:

4 mL × patient’s weight in kg × TBSA percentage (expressed as a decimal)

For example, if a 70 kg patient has burns covering 30% of their body surface area, the calculation would be:

4 mL × 70 kg × 0.30 = 84 liters of fluid over 24 hours

This total volume is then administered as follows:

• First half (42 liters in this example) given over the first 8 hours
• Second half given over the next 16 hours

It’s crucial to note that the 24-hour period starts from the time of the burn, not from the time of hospital admission. If there’s a delay in starting fluid resuscitation, the formula must be adjusted accordingly.

Modifying the Rule of Nines: Accounting for Body Variations

While the Rule of Nines is a valuable tool, it’s not a one-size-fits-all solution. Certain patient populations require modifications to ensure accurate TBSA estimation. Two key groups that often need adjustments are obese patients and infants.

Adaptations for Obese Patients

For individuals classified as obese based on their Body Mass Index (BMI), the standard Rule of Nines can lead to inaccurate estimations. This is because obese patients typically have disproportionately large trunks compared to non-obese individuals. To account for this, the following adjustments are recommended:

• Trunk: Closer to 50% TBSA (increased from 36%)
• Each leg: 15% TBSA (decreased from 18%)
• Each arm: 7% TBSA (decreased from 9%)
• Head: 6% TBSA (decreased from 9%)

Furthermore, the distribution of adipose tissue can affect these percentages:

• Android-shaped obesity (upper body fat distribution): Trunk closer to 53% TBSA
• Gynecoid-shaped obesity (lower body fat distribution): Trunk closer to 48% TBSA

It’s important to note that as the degree of obesity increases, the underestimation of truncal and leg burn involvement becomes more pronounced when using the standard Rule of Nines.

Pediatric Considerations: The Rule of Eights

Infants and young children have significantly different body proportions compared to adults, necessitating a modified approach. For infants weighing less than 10 kg, the “Rule of Eights” is often more appropriate:

• Head: 20% TBSA (increased from 9% in adults)
• Trunk: 32% TBSA (decreased from 36% in adults)
• Each leg: 16% TBSA (decreased from 18% in adults)
• Each arm: 8% TBSA (slightly decreased from 9% in adults)

This adjustment accounts for the proportionately larger heads of infants, which alters the surface area contribution of other major body segments.

Alternative Methods for Burn Area Estimation

While the Rule of Nines is widely used and taught, it’s not the only method available for estimating burn surface area. Are there other tools that healthcare providers can use to assess TBSA in burn patients?

The Lund and Browder Chart

The Lund and Browder chart is considered by many to be more accurate than the Rule of Nines, especially for pediatric patients. This chart takes into account the changing body proportions as a child grows, providing age-specific percentages for different body areas. It divides the body into smaller segments, allowing for a more precise estimation of burn area.

The Palmar Method

For smaller or irregularly shaped burns, the palmar method can be useful. This method is based on the principle that a person’s palm (including fingers) represents approximately 1% of their total body surface area. By using the patient’s palm as a reference, healthcare providers can estimate the size of burns that don’t conform well to the larger body segments used in the Rule of Nines.

Technological Advancements in Burn Assessment

As technology continues to advance, new tools are being developed to enhance the accuracy of burn area estimation. How are these innovations changing the landscape of burn assessment?

3D Scanning and Digital Imaging

Three-dimensional scanning technology is emerging as a promising tool for more precise burn area measurement. These systems can create detailed 3D models of a patient’s body, allowing for highly accurate surface area calculations. While not yet widely available in all healthcare settings, this technology shows great potential for improving the accuracy of TBSA estimations.

Mobile Applications

Several mobile applications have been developed to assist healthcare providers in burn assessment. These apps often incorporate digital planimetry, allowing users to trace burn areas on a touchscreen device. The app then calculates the TBSA based on these tracings, potentially offering greater accuracy than visual estimation alone.

Challenges and Limitations of the Rule of Nines

Despite its widespread use, the Rule of Nines is not without its challenges and limitations. What are some of the key issues that healthcare providers need to be aware of when using this tool?

Interobserver Variability

One of the main challenges with the Rule of Nines is interobserver variability. Different healthcare providers may estimate the same burn area differently, leading to inconsistencies in assessment and treatment planning. This variability can be particularly pronounced in cases of irregularly shaped burns or when assessing patients with body types that deviate significantly from the “standard” proportions used in the Rule of Nines.

Accuracy in Specific Patient Populations

As discussed earlier, the Rule of Nines may not be as accurate for certain patient populations, particularly obese individuals and young children. While modifications exist, they may not fully account for the wide range of body types and proportions seen in clinical practice. This limitation underscores the importance of clinical judgment and the potential need for alternative assessment methods in some cases.

Overestimation of Burn Area

There is a tendency among healthcare providers, especially those less experienced in burn assessment, to overestimate burn areas when using the Rule of Nines. This overestimation can lead to excessive fluid resuscitation, which carries its own risks and complications. Regular training and calibration exercises can help mitigate this issue.

The Future of Burn Assessment: Beyond the Rule of Nines

As our understanding of burn physiology and treatment continues to evolve, so too must our methods of assessment. What does the future hold for burn area estimation and fluid resuscitation planning?

Personalized Burn Assessment

The future of burn assessment likely lies in more personalized approaches that take into account individual patient characteristics. Advanced imaging technologies, combined with artificial intelligence and machine learning algorithms, could potentially create highly accurate, patient-specific models for TBSA estimation and fluid requirement calculations.

Dynamic Fluid Resuscitation Protocols

While current fluid resuscitation formulas like the Parkland formula provide a starting point, there’s growing recognition of the need for more dynamic, individualized approaches. Future protocols may incorporate real-time physiological data, such as urine output, blood pressure, and serum lactate levels, to continuously adjust fluid administration rates and volumes.

Integration of Burn Depth Assessment

Current TBSA estimation methods focus primarily on the surface area affected, but burn depth also plays a crucial role in determining fluid requirements and overall prognosis. Future assessment tools may integrate both area and depth measurements to provide a more comprehensive picture of burn severity and guide treatment more accurately.

In conclusion, while the Rule of Nines remains a valuable tool in burn assessment, it’s important for healthcare providers to understand its limitations and be aware of alternative methods and emerging technologies. As we continue to refine our approach to burn care, the goal remains the same: to provide the most accurate assessment and optimal treatment for each individual patient, ultimately improving outcomes and reducing mortality in severe burn cases.

Rule of Nines – StatPearls

Ross A. Moore; Abdul Waheed; Bracken Burns.

Author Information and Affiliations

Last Update: May 30, 2022.

Introduction

The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by trauma and emergency medicine providers to assess the total body surface area (TBSA) involved in burn patients.  Measurement of the initial burn surface area is important in estimating fluid resuscitation requirements since patients with severe burns will have massive fluid losses due to the removal of the skin barrier. This tool is only utilized for second-degree and third-degree burns (also referred to as partial thickness and full thickness burns) and aids the provider in quick assessment to determine the severity and intravenous fluid needs. Alterations to the Rule of Nines may be made based on body mass index (BMI) and age. The Rule of Nines has been shown to be the most frequently recited algorithm by physicians and nurses for estimating burn surface area in numerous studies. [1][2][3]

The Rule of Nines estimation of body surface area burned is based on assigning percentages to different body areas. The entire head is estimated as 9% (4.5% for anterior and posterior). The entire trunk is estimated at 36% and can be further broken down into 18% for anterior compnents and 18% for the back. The anterior aspect of the trunk can further be divided into chest (9%) and abdomen (9%). The upper extremities total 18% and thus 9% for each upper extremity. Each upper extremity can further be divided into anterior (4.5%) and posterior (4.5%). The lower extremities are estimated at 36%, 18% for each lower extremity. Again this can be further divided into 9% for the anterior and 9% for the posterior aspect. The groin is estimated at 1%.[4][5]

Function

The Rule of Nines functions as a tool to assess second-degree and third-degree total body surface area (TBSA) in burn patients. Once the TBSA is determined and the patient is stabilized, fluid resuscitation may begin often with the use of a formula. Often the Parkland formula is used. It is calculated as 4 mL intravenous (IV) fluid per kilogram of ideal body weight per TBSA percent (expressed as a decimal) over 24 hours. Due to reports of over-resuscitation, other formulas have been proposed such as the Modified Brooke formula, that decrease the intravenous fluid to 2 mL instead of 4 mL. After the total volume of intravenous fluid resuscitation for the first 24 hours is established, the first half of the volume is given over the first 8 hours and the other half is given over the next 16 hours (this is converted to an hourly rate by dividing half the total volume by 8 and 16). The 24-hour volume time starts at the time of the burn. Should the patient present 2 hours after the burn and intravenous fluid resuscitation have not been started, the first half of the volume should be given in 6 hours with the remaining half of fluids running as per protocol. Fluid resuscitation is highly important in the initial management of second-degree and third-degree burns that encompass greater than 20% TBSA as complications of renal failure, myoglobinuria, hemoglobinuria, and multi-organ failure may arise if not aggressively treated early. Mortality has been shown to be higher in patients with greater than 20% TBSA burns that do not receive appropriate fluid resuscitation immediately following the injury.[6][7][8]

Issues of Concern

There is a concern among clinicians of the accuracy of the Rule of Nines pertaining to the obese and pediatric populations. The Rule of Nines can be best used in patients greater than 10 kilograms and less than 80 kilograms if defined by BMI as less than obese. For infants and obese patients special consideration should be take as outlined below:

Obese Patients

• Patients that are defined as obese by BMI have disproportionately large trunks compared to their non-obese counterparts.

• Obese patients have a closer approximation to 50% TBSA of the trunk, 15% TBSA for each leg, 7% TBSA for each arm, and 6% TBSA for the head.

• Android-shaped patients, defined as a preferential trunk and upper body distribution of adipose tissue (abdomen, chest, shoulders, and the nape of the neck), have a torso that is closer to 53% TBSA.

• Gynecoid-shaped patients, defined as a preferential lower body distribution of adipose tissue (lower abdomen, pelvis, and thighs), have a torso that is closer to 48% TBSA.

• As the degree of obesity increases, the degree of underestimation of truncal and leg TBSA burn involvement increases when adhering to the Rule of Nines.

Infants

• Infants have proportionately larger heads which alters the surface area contribution of other major body segments.

• A “Rule of Eights” better approximates infants weighing less than 10 kg.” This rule dictates approximately 32% TBSA for the patient’s trunk, 20% TBSA for the head, 16% TBSA for each leg, and 8% TBSA for each arm.

Despite the efficiency of the Rule of Nines and its penetrance into the surgical and emergency medicine specialties, studies show that at 25% TBSA, 30% TBSA, and 35% TBSA, percentage TBSA is overestimated by 20% when compared to computer-based applications. Overestimation of TBSA burned can lead to excessive intravenous fluid resuscitation giving the potential for volume overload and pulmonary edema with more cardiac demand. Patients with pre-existing comorbidities are at risk for acute cardiac and respiratory decompensation and should be monitored in the intensive care unit (ICU) during the aggressive fluid resuscitation phase, preferably in a burn center.[9][10]

Clinical Significance

The Rule of Nines is a quick and easy tool used for the initial management of resuscitation in burn patients. Studies find that after examining the fully undressed patient, the percentage TBSA can be determined by the Rule of Nines within a few minutes.

Multiple studies found in a literature review stated that the patient’s palm excluding the digits represented approximately 0.5% TBSA and that verification was noted with computer-based applications. The inclusion of the digits to the palm was found to be approximately 0.8% TBSA. The use of the palm, which is the basis for how the Rule of Nines was established, is found to be more appropriate for smaller second-degree and third-degree burns.  It has been noted that the more training a specialist has, the less overestimation is present, especially on smaller burns.

Other Issues

Due to the inherent nature of the error in the human evaluation of burns even in the setting of rules, computer-based applications available for smartphones are being produced to minimize overestimating and underestimating TBSA percentages. The applications are utilizing standardized sizes of male and female models of small, average, and obese sizes. The applications are also moving towards measurements of infants. These computer applications are finding variability in the reporting of TBSA percentages by up to 60% overestimation of burn surface area down to 70% underestimation.

Intravenous fluid resuscitation guided by the Rule of Nines stands only for patients that have greater than 20% TBSA, and these patients should be transported to the nearest trauma center. Except for special areas, such as the face, genitals, and hands, that need to be seen by a specialist, transfer to major trauma centers are only necessary for greater than 20% TBSA burns. The American Burn Association (ABA) also has defined criteria of which patients should be transferred to a burn center.

Once fluid resuscitation has been initiated, it is important to identify if appropriate perfusion, hydration, and renal function are present. The resuscitation derived from the Rule of Nines and intravenous fluid formula (Parkland, Modified Brooke, among others) should be closely monitored and adjusted as these initial values are guidelines. The management of severe burns is a fluid process requiring constant monitoring and alterations. Lack of attention to details can result in higher morbidity and mortality as these patients are critically ill.

Enhancing Healthcare Team Outcomes

The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by health care professionals to assess the total body surface area (TBSA) involved in burn patients. Measurement of the initial burn surface area by the healthcare team is important in estimating fluid resuscitation requirements since patients with severe burns have massive fluid losses due to the removal of the skin barrier. The activity updates healthcare teams on the Rule of Nine use in burn victims which will produce better patient outcomes. [Level V]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Diagram of rule of 9s for adults. Contributed from Wiki commons user Jmarchn, CC By-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0/

Figure

Diagram of rule of 9s modifications for pediatric patients. Contributed by Rian Kabir, MD

References

1.

Cheah AKW, Kangkorn T, Tan EH, Loo ML, Chong SJ. The validation study on a three-dimensional burn estimation smart-phone application: accurate, free and fast? Burns Trauma. 2018;6:7. [PMC free article: PMC5828346] [PubMed: 29497619]

2.

Tocco-Tussardi I, Presman B, Huss F. Want Correct Percentage of TBSA Burned? Let a Layman Do the Assessment. J Burn Care Res. 2018 Feb 20;39(2):295-301. [PubMed: 28877135]

3.

Borhani-Khomani K, Partoft S, Holmgaard R. Assessment of burn size in obese adults; a literature review. J Plast Surg Hand Surg. 2017 Dec;51(6):375-380. [PubMed: 28417654]

4.

Ali SA, Hamiz-Ul-Fawwad S, Al-Ibran E, Ahmed G, Saleem A, Mustafa D, Hussain M. Clinical and demographic features of burn injuries in karachi: a six-year experience at the burns centre, civil hospital, Karachi. Ann Burns Fire Disasters. 2016 Mar 31;29(1):4-9. [PMC free article: PMC5108226] [PubMed: 27857643]

5.

Thom D. Appraising current methods for preclinical calculation of burn size – A pre-hospital perspective. Burns. 2017 Feb;43(1):127-136. [PubMed: 27575669]

6.

Parvizi D, Giretzlehner M, Dirnberger J, Owen R, Haller HL, Schintler MV, Wurzer P, Lumenta DB, Kamolz LP. The use of telemedicine in burn care: development of a mobile system for TBSA documentation and remote assessment. Ann Burns Fire Disasters. 2014 Jun 30;27(2):94-100. [PMC free article: PMC4396802] [PubMed: 26170783]

7.

Williams RY, Wohlgemuth SD. Does the “rule of nines” apply to morbidly obese burn victims? J Burn Care Res. 2013 Jul-Aug;34(4):447-52. [PubMed: 23702858]

8.

Vaughn L, Beckel N, Walters P. Severe burn injury, burn shock, and smoke inhalation injury in small animals. Part 2: diagnosis, therapy, complications, and prognosis. J Vet Emerg Crit Care (San Antonio). 2012 Apr;22(2):187-200. [PubMed: 23016810]

9.

Prieto MF, Acha B, Gómez-Cía T, Fondón I, Serrano C. A system for 3D representation of burns and calculation of burnt skin area. Burns. 2011 Nov;37(7):1233-40. [PubMed: 21703768]

10.

Neaman KC, Andres LA, McClure AM, Burton ME, Kemmeter PR, Ford RD. A new method for estimation of involved BSAs for obese and normal-weight patients with burn injury. J Burn Care Res. 2011 May-Jun;32(3):421-8. [PubMed: 21562463]

Disclosure: Ross Moore declares no relevant financial relationships with ineligible companies.

Disclosure: Abdul Waheed declares no relevant financial relationships with ineligible companies.

Disclosure: Bracken Burns declares no relevant financial relationships with ineligible companies.

Rule of Nines – StatPearls

Ross A. Moore; Abdul Waheed; Bracken Burns.

Author Information and Affiliations

Last Update: May 30, 2022.

Introduction

The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by trauma and emergency medicine providers to assess the total body surface area (TBSA) involved in burn patients.  Measurement of the initial burn surface area is important in estimating fluid resuscitation requirements since patients with severe burns will have massive fluid losses due to the removal of the skin barrier. This tool is only utilized for second-degree and third-degree burns (also referred to as partial thickness and full thickness burns) and aids the provider in quick assessment to determine the severity and intravenous fluid needs. Alterations to the Rule of Nines may be made based on body mass index (BMI) and age. The Rule of Nines has been shown to be the most frequently recited algorithm by physicians and nurses for estimating burn surface area in numerous studies.[1][2][3]

The Rule of Nines estimation of body surface area burned is based on assigning percentages to different body areas. The entire head is estimated as 9% (4.5% for anterior and posterior). The entire trunk is estimated at 36% and can be further broken down into 18% for anterior compnents and 18% for the back. The anterior aspect of the trunk can further be divided into chest (9%) and abdomen (9%). The upper extremities total 18% and thus 9% for each upper extremity. Each upper extremity can further be divided into anterior (4.5%) and posterior (4.5%). The lower extremities are estimated at 36%, 18% for each lower extremity. Again this can be further divided into 9% for the anterior and 9% for the posterior aspect. The groin is estimated at 1%. [4][5]

Function

The Rule of Nines functions as a tool to assess second-degree and third-degree total body surface area (TBSA) in burn patients. Once the TBSA is determined and the patient is stabilized, fluid resuscitation may begin often with the use of a formula. Often the Parkland formula is used. It is calculated as 4 mL intravenous (IV) fluid per kilogram of ideal body weight per TBSA percent (expressed as a decimal) over 24 hours. Due to reports of over-resuscitation, other formulas have been proposed such as the Modified Brooke formula, that decrease the intravenous fluid to 2 mL instead of 4 mL. After the total volume of intravenous fluid resuscitation for the first 24 hours is established, the first half of the volume is given over the first 8 hours and the other half is given over the next 16 hours (this is converted to an hourly rate by dividing half the total volume by 8 and 16). The 24-hour volume time starts at the time of the burn. Should the patient present 2 hours after the burn and intravenous fluid resuscitation have not been started, the first half of the volume should be given in 6 hours with the remaining half of fluids running as per protocol. Fluid resuscitation is highly important in the initial management of second-degree and third-degree burns that encompass greater than 20% TBSA as complications of renal failure, myoglobinuria, hemoglobinuria, and multi-organ failure may arise if not aggressively treated early. Mortality has been shown to be higher in patients with greater than 20% TBSA burns that do not receive appropriate fluid resuscitation immediately following the injury.[6][7][8]

Issues of Concern

There is a concern among clinicians of the accuracy of the Rule of Nines pertaining to the obese and pediatric populations. The Rule of Nines can be best used in patients greater than 10 kilograms and less than 80 kilograms if defined by BMI as less than obese. For infants and obese patients special consideration should be take as outlined below:

Obese Patients

• Patients that are defined as obese by BMI have disproportionately large trunks compared to their non-obese counterparts.

• Obese patients have a closer approximation to 50% TBSA of the trunk, 15% TBSA for each leg, 7% TBSA for each arm, and 6% TBSA for the head.

• Android-shaped patients, defined as a preferential trunk and upper body distribution of adipose tissue (abdomen, chest, shoulders, and the nape of the neck), have a torso that is closer to 53% TBSA.

• Gynecoid-shaped patients, defined as a preferential lower body distribution of adipose tissue (lower abdomen, pelvis, and thighs), have a torso that is closer to 48% TBSA.

• As the degree of obesity increases, the degree of underestimation of truncal and leg TBSA burn involvement increases when adhering to the Rule of Nines.

Infants

• Infants have proportionately larger heads which alters the surface area contribution of other major body segments.

• A “Rule of Eights” better approximates infants weighing less than 10 kg.” This rule dictates approximately 32% TBSA for the patient’s trunk, 20% TBSA for the head, 16% TBSA for each leg, and 8% TBSA for each arm.

Despite the efficiency of the Rule of Nines and its penetrance into the surgical and emergency medicine specialties, studies show that at 25% TBSA, 30% TBSA, and 35% TBSA, percentage TBSA is overestimated by 20% when compared to computer-based applications. Overestimation of TBSA burned can lead to excessive intravenous fluid resuscitation giving the potential for volume overload and pulmonary edema with more cardiac demand. Patients with pre-existing comorbidities are at risk for acute cardiac and respiratory decompensation and should be monitored in the intensive care unit (ICU) during the aggressive fluid resuscitation phase, preferably in a burn center.[9][10]

Clinical Significance

The Rule of Nines is a quick and easy tool used for the initial management of resuscitation in burn patients. Studies find that after examining the fully undressed patient, the percentage TBSA can be determined by the Rule of Nines within a few minutes.

Multiple studies found in a literature review stated that the patient’s palm excluding the digits represented approximately 0. 5% TBSA and that verification was noted with computer-based applications. The inclusion of the digits to the palm was found to be approximately 0.8% TBSA. The use of the palm, which is the basis for how the Rule of Nines was established, is found to be more appropriate for smaller second-degree and third-degree burns. It has been noted that the more training a specialist has, the less overestimation is present, especially on smaller burns.

Other Issues

Due to the inherent nature of the error in the human evaluation of burns even in the setting of rules, computer-based applications available for smartphones are being produced to minimize overestimating and underestimating TBSA percentages. The applications are utilizing standardized sizes of male and female models of small, average, and obese sizes. The applications are also moving towards measurements of infants. These computer applications are finding variability in the reporting of TBSA percentages by up to 60% overestimation of burn surface area down to 70% underestimation.

Intravenous fluid resuscitation guided by the Rule of Nines stands only for patients that have greater than 20% TBSA, and these patients should be transported to the nearest trauma center. Except for special areas, such as the face, genitals, and hands, that need to be seen by a specialist, transfer to major trauma centers are only necessary for greater than 20% TBSA burns. The American Burn Association (ABA) also has defined criteria of which patients should be transferred to a burn center.

Once fluid resuscitation has been initiated, it is important to identify if appropriate perfusion, hydration, and renal function are present. The resuscitation derived from the Rule of Nines and intravenous fluid formula (Parkland, Modified Brooke, among others) should be closely monitored and adjusted as these initial values are guidelines. The management of severe burns is a fluid process requiring constant monitoring and alterations. Lack of attention to details can result in higher morbidity and mortality as these patients are critically ill.

Enhancing Healthcare Team Outcomes

The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by health care professionals to assess the total body surface area (TBSA) involved in burn patients. Measurement of the initial burn surface area by the healthcare team is important in estimating fluid resuscitation requirements since patients with severe burns have massive fluid losses due to the removal of the skin barrier. The activity updates healthcare teams on the Rule of Nine use in burn victims which will produce better patient outcomes. [Level V]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Diagram of rule of 9s for adults. Contributed from Wiki commons user Jmarchn, CC By-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0/

Figure

Diagram of rule of 9s modifications for pediatric patients. Contributed by Rian Kabir, MD

References

1.

Cheah AKW, Kangkorn T, Tan EH, Loo ML, Chong SJ. The validation study on a three-dimensional burn estimation smart-phone application: accurate, free and fast? Burns Trauma. 2018;6:7. [PMC free article: PMC5828346] [PubMed: 29497619]

2.

Tocco-Tussardi I, Presman B, Huss F. Want Correct Percentage of TBSA Burned? Let a Layman Do the Assessment. J Burn Care Res. 2018 Feb 20;39(2):295-301. [PubMed: 28877135]

3.

Borhani-Khomani K, Partoft S, Holmgaard R. Assessment of burn size in obese adults; a literature review. J Plast Surg Hand Surg. 2017 Dec;51(6):375-380. [PubMed: 28417654]

4.

Ali SA, Hamiz-Ul-Fawwad S, Al-Ibran E, Ahmed G, Saleem A, Mustafa D, Hussain M. Clinical and demographic features of burn injuries in karachi: a six-year experience at the burns centre, civil hospital, Karachi. Ann Burns Fire Disasters. 2016 Mar 31;29(1):4-9. [PMC free article: PMC5108226] [PubMed: 27857643]

5.

Thom D. Appraising current methods for preclinical calculation of burn size – A pre-hospital perspective. Burns. 2017 Feb;43(1):127-136. [PubMed: 27575669]

6.

Parvizi D, Giretzlehner M, Dirnberger J, Owen R, Haller HL, Schintler MV, Wurzer P, Lumenta DB, Kamolz LP. The use of telemedicine in burn care: development of a mobile system for TBSA documentation and remote assessment. Ann Burns Fire Disasters. 2014 Jun 30;27(2):94-100. [PMC free article: PMC4396802] [PubMed: 26170783]

7.

Williams RY, Wohlgemuth SD. Does the “rule of nines” apply to morbidly obese burn victims? J Burn Care Res. 2013 Jul-Aug;34(4):447-52. [PubMed: 23702858]

8.

Vaughn L, Beckel N, Walters P. Severe burn injury, burn shock, and smoke inhalation injury in small animals. Part 2: diagnosis, therapy, complications, and prognosis. J Vet Emerg Crit Care (San Antonio). 2012 Apr;22(2):187-200. [PubMed: 23016810]

9.

Prieto MF, Acha B, Gómez-Cía T, Fondón I, Serrano C. A system for 3D representation of burns and calculation of burnt skin area. Burns. 2011 Nov;37(7):1233-40. [PubMed: 21703768]

10.

Neaman KC, Andres LA, McClure AM, Burton ME, Kemmeter PR, Ford RD. A new method for estimation of involved BSAs for obese and normal-weight patients with burn injury. J Burn Care Res. 2011 May-Jun;32(3):421-8. [PubMed: 21562463]

Disclosure: Ross Moore declares no relevant financial relationships with ineligible companies.

Disclosure: Abdul Waheed declares no relevant financial relationships with ineligible companies.

Disclosure: Bracken Burns declares no relevant financial relationships with ineligible companies.

Read online “1000 tips from an experienced doctor. How to help yourself and loved ones in extreme situations”, Viktor Kovalev – Litres

What is this book about

Don’t you think, friends, that the author and publishers got a little excited? The fate of a book on surgical topics always inspires considerable concern. Will it be read, that is the question.

The sweetest thing to do is to browse at your leisure something about tasty and healthy food, about freshly squeezed fruit and vegetable juices, aromatic herbs, vitamins, incense. And also about the jar, fresh air, physical education …

Why flip through? Even thinking about all these wonderful things fills the mind and heart with optimism and cheerfulness. Just like the viewers and participants of the Malakhov + TV show.

On the contrary, at the word “surgery” the most unperturbed person has completely different thoughts.

Bone crunching, blood, wounds, cries of pain, and so on… What a positive attitude and attitude when it becomes cold in the stomach and dry in the mouth.

And who, pray tell, without special training and experience, dares to help himself or his neighbor surgically? It’s scary to even imagine. For a non-professional, the mention of scalpels, bandages, crutches, etc. will cause more horror than a desire to broaden one’s horizons.

But let’s try to think a little, so to speak, we will strain the convolutions. Sometimes this is useful.

Fans of reading about health, illness and self-healing are well aware of the axiom that the most important conditions for a long, happy and serene life are, firstly, the harmony of soul and body; secondly, good environmental conditions: good food, good housing, a wonderful climate – and so on.

There seems to be nothing to argue about. At first glance, our health is entirely dependent on us. And indeed, people cope with most of the ailments without resorting to the help of doctors – as they say, they are treated on their own.

However, in medical circles, the word self-medication is given a disapproving or even condemning meaning.

In the conversations of doctors among themselves, self-treatment refers to the attempts of patients to improve their deteriorating health by useless medication or, so to speak, “improving” procedures. The restraint, and even indignation of professionals who often have to eliminate the fruits of such activity, is quite understandable.

Every practicing physician will tell you that good habits and exemplary behavior alone cannot protect oneself from all manifestations of life, including diseases.

It is naive to hope that health can be preserved or increased by scrupulous observance of as many hygiene recommendations and health advice as possible.

However, everyone is aware of the limited possibilities of preventive measures and efforts. A glass of carrot juice will not protect you from fate. At the same time, the unconditional denial of independent actions in relation to one’s own health is not entirely fair.

First of all, everyone needs basic medical knowledge and skills, as they can play a saving role in the life of any person.

Sometimes circumstances develop in such a way that a person without medical education is suddenly faced with the need to save health, and even life. It doesn’t matter if it’s yours or someone else’s. In acute situations, the mind begins to work surprisingly quickly and clearly. And it’s good if there is something to remember in the far corners of our memory.

Let’s take the next step in our reasoning and reflections.

The position of people who lack the determination to take any medical action on their own is worthy of understanding – in all ages, healing has been based on the commandment “do no harm.”

With self-treatment, the situation is exactly the same: the main thing is to stop in time. If you don’t know what to do, don’t do anything. When you come face to face with a disease, it is worth giving up arrogance and nihilism about medicine. To remember that there are doctors – isn’t this the beginning of the right treatment?

Reasonable decisions concerning one’s own health are much easier to make when a person understands what surgery is in general; what considerations are guided by a doctor recommending an operation; what to expect in the postoperative period and so on. To have more or less intelligible ideas about all this is not superfluous.

People who are far from medicine, most often have no idea about how everyday life goes in the hospital walls. There is no need to be surprised at this – after all, the words “hospital”, “hospital”, “hospitalization” do not attract curiosity. However, any sane person will agree that the minimum information about the written and unwritten rules of hospital life, and even obtained first-hand, may also be needed by everyone.

How to get settled in the ward, how to establish relationships with doctors, nurses, nurses and roommates – all these everyday tasks are solved quite simply, if you know from which side to take them.

But professional assistance to a sick or injured person is far from everything. Those patients who fight for recovery shoulder to shoulder with doctors and sisters recover faster after operations.

And those who have already recovered must continue to take care of their health. Without the active participation of the patient himself, rehabilitation (restoration of a full-fledged lifestyle after surgery) is impossible.

Therefore, rational nutrition, physical education, self-massage, baths and other good habits can be called surgical self-treatment without exaggeration.

If reading this book will help at least a few people overcome with honor the problems that unexpectedly arose in their lives, we (the author and publishers) will be able to breathe a sigh of relief – it means that our labors were not in vain.

Chapter I

Short course of home “needlework”. First aid for injuries, burns, frostbite, bruises and sprains

Help for superficial wounds

“Needlework” is a literal translation from Greek, and not a flat joke of a novice writer. The word “surgery” since the time of Hippocrates means “action with the hands.”

Let’s start with ordinary incidents. Everyone has been cut or scratched. There is a life-tested set of rules for the treatment of superficial wounds, more often they are called abrasions or scratches.

We will act on the same principles as surgeons. To treat a wound, you need:

– stop bleeding;

– remove dirt from the wound;

– “close” the wound – that is, to prevent its further contamination.

How to stop heavy bleeding, will be described in more detail in the chapter “Ministry of Emergency Situations”. With scratches and abrasions, there is no heavy bleeding.

It is best to clean the abrasion with a 3% hydrogen peroxide solution. The foam, which is formed when hydrogen peroxide interacts with blood, removes dirt and most microbes from the wound; the active oxygen released at the same time promotes the formation of blood clots in the capillaries.

So, hydrogen peroxide simultaneously cleanses, disinfects the wound and stops bleeding from small vessels.

If there is no hydrogen peroxide at home, it is enough to wash the abrasion with water (at least from the tap, even from the well).

When the wound is very dirty, feel free to use soap and water.

Do not pour alcohol, gasoline and other organic solvents on a fresh wound – these substances increase tissue damage.

After washing the wound, dry it. To do this, remember how to remove a drop of paint that has fallen on the glass. Blot the wound with a loose cloth or cotton.

Moving the swab back and forth over the wound, and even with force, can damage blood clots, and this will lead to the resumption of bleeding.

After drying the wound, treat the edges of the skin around it with a solution of brilliant green (“brilliant green”), cologne, vodka or other strong liquor. This is more accurate if you use a tampon made from a piece of cotton wool wound around a match. Now special cotton buds are also sold.

You can treat the edges of wounds with tinctures of medicinal plants – calendula, eucalyptus.

However, it is better to use aqueous solutions of chlorhexidine or miramistin.

These preparations are truly suitable anywhere. Their use does not cause pain and burning. Chlorhexidine and miramistin can be used to disinfect a fresh abrasion, rinse the eye or throat with inflammation, and rinse the mouth after tooth extraction.

Chlorhexidine and miramistin are also suitable for dressing wounds that are starting to become inflamed or festering.

It is advisable to have at least one of these medicines in your first aid kit. However, do not forget about the centuries-old use of iodine tincture. There are also more modern drugs based on iodine – betadine or iodopyrone.

But remember that iodine preparations can cause burns or allergic reactions in some people.

After you have washed and disinfected the wound, cover it with a germicidal band-aid. If a bactericidal patch is not at hand, you can seal the wound with a simple adhesive tape.

When using regular band-aids, remember to allow the wound to breathe. Therefore, before sticking the patch, cover the wound with a piece of gauze or other absorbent cloth. If the tissue is not sterile, soak it in chlorhexidine, miramistin, or any alcohol tincture (except iodine!) and wring it dry before putting it on the wound.

If you don’t have a band-aid at home, you can cover the abrasion with a bandage. We will talk about how to properly bandage and bandages in general a little later.

Bruised, chopped and stab wounds

It is clear that a doctor is consulted for injuries more severe than abrasions. When the wound “gaps”, it needs to be “closed”. To do this, the doctor brings its edges together with sutures or special staples. With a small wound (up to 5 centimeters long), this can be done with strips of adhesive tape.

Bruised wounds should not be treated at home, that is, those inflicted with an ax, hammer and other heavy objects. Animal bite wounds should also be examined by a surgeon. It is possible that he will be forced to first remove the damaged tissue and only then sew up the wound. This operation is called “primary debridement”.

Stab wounds are especially dangerous. Their external skin damage is small, and the wound channel is long and narrow. In this case, the infection is carried deep into the tissues, which often leads to severe purulent complications. Therefore, if you stepped on or sat on a nail, pierced your hand with an awl or a needle, do not wait until inflammation begins. Immediately after the incident, go to the emergency room or hospital emergency department. Of course, after the bandage is applied.

How to close the edges of a wound with adhesive tape.

Why, when and how wounds are bandaged

Once again, let’s recall the tasks that need to be solved when you treat wounds.

There are three such tasks:

1) stop bleeding;

2) remove dirt from the wound;

3) prevent further contamination of the wound.

Dressings help to solve two of these three tasks – to stop bleeding and prevent further contamination of the wound.

The main and mortal danger in severe wounds is rapid blood loss. So the first thing to do is stop the bleeding. When the blood flows in a stream or a pulsating stream, do not waste time thinking that you will introduce an infection into the wound. Any wound is already contaminated with germs.

Most bleeding can be controlled with a pressure bandage. Cover the wound with the cleanest thing you can get your hands on. If there is no sterile gauze, take a clean handkerchief, a piece of a shirt or dress, a paper napkin, a piece of toilet paper folded several times. In a word, any more or less pure material capable of absorbing moisture. After closing the wound with a napkin or something that replaces it, proceed to bandaging.

How to fix the dressing for head wounds.

With the first two turns of the bandage, secure the dressing used to cover the wound. The first turn presses the upper edge of the napkin, the second – the bottom. Do not try to pull the bandage tight on the first wraps – you can move the napkin covering the wound. When making a turn of the bandage, cover the previous layer of the bandage by half the width of the bandage.

Increase the tension of the bandage with each turn. Now you can already put cotton wool to increase the pressure on the wound.

Bleeding from head wounds is also stopped by a pressure bandage. How to make sure that such a bandage does not fall off is shown in the figure.

Perhaps the sling-like bandage of head wounds is one of the clearest proofs that everything ingenious is simple. The ends of the “reins”, after the wound is covered with 4-5 layers of bandage, are tied together. This bandage will never fall off. When applying a bandage, either the victim himself or an assistant can hold the “reins”.

Concluding the conversation about first aid for wounds, it is necessary to draw attention to a very important detail.

Do not attempt to remove glass fragments or other objects that are firmly stuck in wounds. This can lead to renewed bleeding.

About the features of stopping arterial bleeding (when blood flows out of the wound in a pulsating stream) will be described in the chapter “Ministry of Emergency Situations” (meaning the rules for applying a tourniquet).

Topical treatment of fresh wounds requires the use of sterile dressings and careful asepsis when applying the dressing. In a matter of minutes, it is most likely impossible to create an operating room or a clean dressing room at home or in a country-garden-field environment.

Therefore, it is wise to take advantage of the experience of emergency doctors, they prefer ready-made sterile dressings. Therefore, both in the home and in the car first aid kit there should be some supply of sterile bandages and wipes in intact packages.

When going to the forest, in addition to a knife and matches, take with you a sterile bandage in a package.

Most first aid kits also include a swab bandage IPP (individual dressing package). It is a sterile soft pad placed over a wound to absorb blood and secretions and to prevent infection from entering the wound. The PPI kit includes a bandage with which the pad is fixed over the wound. The rubberized sheath of the PPI can be used for penetrating chest wounds. What to do with such wounds is described in the chapter “Ministry of Emergency Situations for myself”.

An impromptu IPP is easy to make: wrap several layers of bandage around a 5 x 10 cm sheet of cotton. The soft pad is ready. You can bandage it to the wound.

In situations where sterile bandages and napkins are nowhere to be found, anything that can wrap or cover the injured part of the body can be used as a dressing – a towel, a piece of sheet, a scarf, a scarf. In extreme cases, the wound can be covered with several layers of toilet paper .

Each dressing is considered temporary, and after first aid has been given, it is best to go to the emergency room.

If the accident happened in the forest, you can put a handful of sphagnum moss on the wound – it has a hemostatic and disinfectant effect.

So, after the bleeding has been stopped, the most important thing is to prevent further contamination of the wound, if possible, by covering it with a bandage.

First aid for burns and frostbite

Burns

In everyday life, burns most often occur in the kitchen and bathroom – there is always a danger of suffering from hot water, steam, pots, hot pans, burners, irons, etc.

Burns are serious injuries. The severity of burns is determined not only by the degree of tissue damage. It depends on the size of the burned surface, and on which area of ​​the body is burned.

Only minor burns can be treated at home. People with more severe burns must be taken to the hospital.

How the severity of burns is determined

Burns of I, II and III degrees are distinguished depending on the depth of skin damage.

Tactics of treatment and terms of healing of burn wounds depend on the degree of the burn.

First degree burns are the most mild. The thickness of the skin during burns of the first degree of severity is not damaged. The surface of the burned area becomes pink or red but remains dry and may show small blisters. First-degree burns take several days to heal – approximately one week.

Butadione ointment or celestoderm with garamycin is excellent for sunburn. If you are going to relax in hot countries and lie in the sun to your heart’s content, along with sunscreen, be sure to take one of these products with you. This will help you avoid familiarity with the peculiarities of Egyptian, Turkish or Thai healthcare.

Second degree burns damage part of the thickness of the skin. Combustiologists (doctors who treat thermal injuries – burns and frostbite) distinguish between superficial and deep second-degree burns.

First and second degree skin lesions can be caused by very short exposure to hot liquids or steam. For example, burn blisters occur even after 30 seconds of contact with water at a temperature of 54 ° C.

In superficial second-degree burns, the skin becomes bright red and moist, blistered, and sensitive.

Most of these burns are treated on an outpatient basis. In other words, the patient stays at home and goes to the clinic for dressings. Healing will take from 10 days to three weeks.

In deep second-degree burns, the skin turns dark red or yellow-white. It is covered with large bubbles. The healing of such burns is extremely slow – at least three weeks, and after healing, rough tightening scars often form. Often a significant part of the treatment has to be done in the hospital.

Third-degree or full-thickness burns of the skin are caused by prolonged exposure to hot water, steam, incandescent objects, flames, high voltage electrical current, or concentrated chemicals.

This destroys all layers of the skin. The burned area looks like a pearly white, charred or “parchment” area. Sensitivity in the affected area disappears, as the nerve endings of the skin are destroyed by the action of high temperature.

Treatment of people with third-degree burns is carried out either in specialized burn centers or in the departments of purulent surgery. Often, such patients require skin transplantation, since self-restoration of the skin is impossible.

How is the prevalence of burns determined?

For first-degree burns, the area of ​​the burn lesion is usually not measured, because this does not affect the choice of treatment tactics.

For deeper injuries, combustiologists draw up a diagram of the burn surface to accurately determine the area of ​​the lesion.

In adult patients, the proportion of affected skin surface can be determined using the Rule of Nine.

According to this rule, the entire surface of the body is divided into segments, each of which is approximately 9% of the total body surface: head and neck – 9%; upper limbs – 9% each, lower limbs – 18% each, front and back surfaces of the body – 18% each; genitals and perineum – 1% each.

In children, these ratios are different, since their head and neck make up a relatively large part of the body surface, and the lower limbs a smaller one.

Burns that are small or unevenly distributed can be measured with the patient’s hand, since the area of ​​the palm of the hand is approximately 1% of the total body surface.

If the burned area can be covered with two palms, then 2% of the body is burned, with three palms – the affected area is 3%, etc. (naturally, when measuring the affected area, you do not need to touch the burned surface).

First-degree burns of any area and superficial second-degree burns, occupying no more than 5% of the body surface, can be considered conditionally light.

Remember! Even minor burns to the face, hands, perineum, eyes, mouth, nose, and other parts of the respiratory tract are considered severe injuries. Such burns should be treated under medical supervision!

“Rule of Nine”.

Rule 9 – Rules of the Holy Apostles

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On the inadmissibility of the faithful to leave the Liturgy without participating in prayer and communion.

All those faithful who enter the church and listen to the Scriptures, but do not remain in prayer even during Holy Communion, should be excommunicated as violating order in the church.

Πάντας τοὺς εἰσιόντας πιστούς, καὶ τῶν γραφῶν ἀκούοντας, μὴ παραμένο ντας δὲ τῇ προσευχῇ καὶ τῇ ἁγίᾳ μεταλήψει, ὡς ἀταξίαν ἐμποιοῦντας τῇ ἐκκλη σίᾳ ἀφορίζεσθαι χρή.

Trul.66, 80; Antioch.2; Sard.11

Zonara . This rule requires that during the performance of the holy sacrifice, everyone should remain to the end in prayer and holy communion. For then it was also required of the laity that they constantly commune. There is a canon of the Council of Sardis and another of Trull, and also a canon of the Council of Antioch, which prescribes that he who, being present at divine services on three Sundays, does not take communion, be subject to excommunication. Therefore, the present rule also excommunicates those who do not come to prayer and Holy Communion, as violating the order. And the second canon of the Council of Antioch speaks of this.

Aristen . Excommunicate those who do not remain in prayer and communion. One should be excommunicated who does not stay in the church to the end, but leaves the church even during the celebration of the Holy Liturgy; for such a one produces disorder in the church.

Valsamon . The definition of this rule is very strict. For he excommunicates those who are in the church, but do not remain to the end and do not partake. And other rules similarly determine that everyone should be ready and worthy of communion, and excommunicate those who do not partake on three Sundays.

Slavic helmsman . Stay in the church praying until the last prayer. Yes, there will be excommunications for those who do not arrive in the church until the last prayer, nor those who receive communion.

Interpretation of . Even they do not stay in the holy church until the last prayer, but still eat and perform the holy service, they come out of the church, such as doing outrage in the holy church, let them go away.