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What is the rules of nines: What Is It, and How Is It Used?

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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.

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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.

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Algorithm of action in case of burns – News

Burns are one of the most common fire injuries. Therefore, it is important for all of us to know the techniques and methods of providing first aid to victims of burns.

The tragic consequences of burns would have been much less if help had been provided correctly from the first minutes. It is enough to apply a scheme of actions available to everyone directly at the scene of the incident in order not only to reduce pain, but also to significantly increase the likelihood of saving the victim.

As a rule, burns received in a fire are thermal, that is, obtained from direct exposure to fire, hot metal objects, flashed combustible liquid. By the way, thermal burns also include injuries received from boiling water or hot water.

It is important to be able to distinguish between degrees of burns. There are 4 degrees of burns:

I degree – skin redness, swelling. The mildest degree of burn.

II degree – the appearance of blisters filled with a clear liquid (blood plasma).

III degree – necrosis of all layers of the skin. Proteins of skin cells and blood coagulate and form a dense scab, under which there are damaged and dead tissues.

IV degree – charring of tissues. This is the most severe form of a burn, in which the skin, muscles, tendons, and bones are damaged.

The first factor influencing the severity of the victim’s condition is the area of ​​the burn. You can determine the area of ​​the burn using the “rule of nines”: the skin surface of the palm is 1% of the body surface, the skin surface of the hand is 9%, the skin surface of the leg – 18%, the skin surface of the chest in front and behind – 9% each, the skin surface of the abdomen and lower back of the abdomen and lower back – 9% each. Burn of the perineum and genitals – 10% of the burn area. Burns in these areas are shock injuries. There are superficial and deep burns; limited (less than 10%) and extensive (more than 10%).

REMEMBER! With large burns, life-threatening dehydration occurs.

BURN SCHEDULE:

1. Stop exposure to high temperature on the victim, extinguish the flame on his clothes, remove the victim from the affected area.

2. Specify the nature of the burn (flame, hot water, chemicals, etc.), as well as area and depth. Wrap the victim in a clean sheet and immediately deliver to a medical facility.
3. Carry out transport immobilization, in which the burned areas of the body should be in the most stretched position.

4. With a small burn, the burnt area can be placed under a stream of cold water from a tap for 10-15 minutes, with extensive burns this should not be done.

5. It is better to cut the clothes in the places of the burn and apply an aseptic bandage around the burn, while cotton should not be applied.

6. When transporting the wounded to a medical institution, ensure that he is calm.

IT IS FORBIDDEN:
– to leave the victim alone;

– apply ointment, cream, vegetable oil to the burned area, sprinkle with powders;

– pierce bubbles;

– remove clothing from the burned area;

– in case of a burn of the oral cavity, give food and drink.

The Main Directorate of the Ministry of Emergency Situations of Russia for the Kabardino-Balkarian Republic reminds:

If you are in an emergency and you need the help of firefighters or rescuers – a single number to call all emergency services from the mobile phone “112” and “01” from the stationary.

degrees, first aid and treatment at various stages

Types of burns

  • Thermal
  • Chemical
  • Electrical
  • Solar

Thermal burns

Most common thermal burns 2 . They occur when the skin comes into contact with hot liquids, boiling water, steam, with hot surfaces and from intense thermal radiation, as well as when interacting with a flame.

Thermal skin burn

Thermal burn occurs as a result of high temperature exposure to the skin and underlying tissues. How to provide first aid, and how are such injuries treated?

More

Chemical burns

Chemical burns 2 are caused by contact with the skin solutions of acids, alkalis. The damaging effect begins from the moment the aggressive liquid hits the skin until the completion of the chemical reaction. The boundaries of chemical burns are clear. Under the influence of nitric acid, a scab (crust) of a yellow-green hue is formed, sulfuric acid – black, hydrochloric acid – light yellow.

Household chemicals must be kept out of the reach of children!

Electrical burns

Electrical burns – local manifestations of electrical injury 2 . As a rule, electrical burns and electrical trauma are combined. The damaging effect of electric current on the skin and soft tissues occurs in response to the action of converted electrical energy into heat.

Keep electrical appliances, sockets and exposed wires away from small children.

Sunburn

Sunburn , or solar dermatitis, results from prolonged skin exposure to ultraviolet (UV) radiation. The degree of damage to the skin depends on the duration of exposure to radiation and the phototype of the skin. The lighter the skin, the faster sunburn can occur. Therefore, before going out into the sun, it is very important to treat delicate baby skin with special protective agents.

Degrees of severity of burns

Burns of the 1st degree

Immediately after contact with the damaging factor, pain, burning, the skin turns red, and swelling of the skin that has been exposed to aggressive effects occurs.

Second degree burn

Second degree burns result in the death of the surface layer of the skin – the epidermis. The skin acquires a bright red color, puffiness appears, blisters form with a transparent yellowish content. The blisters break open, exposing a bright pink wound surface.

A feature of a second degree chemical burn is the absence of blistering. A crust is immediately formed from the dead layer of the epidermis, or the surface layer of the skin is completely torn off.

III degree burns

Not only the epidermis dies, but also the upper layers of the dermis. Bubbles may also form.

When scalded with steam or hot water, a sign of III degree burns is a whitish-gray coating, a wet crust.

Dry light brown crust on contact with flame.

Burns III-b degree

It is characterized by the death of the entire thickness of the skin and sometimes subcutaneous fat.

When burned with steam or hot water, the skin becomes soft, resembling a pale gray dough in consistency.

Flame burns form a hard, dark brown crust.

IV degree burns

At this stage, not only the skin and subcutaneous fat die, but also the underlying muscle membranes (fascia), muscles, tendons and bones. The scab (crust) is thick, dense with signs of charring.

In case of severe burns with acid, a dry dense crust is formed, in case of burns with alkali, the crust is soft for the first few days, then either undergoes purulent melting or dries up.

First aid for burns

Depending on the type of burn received, the first aid algorithm will be slightly different.

First aid for thermal burns

Interrupt exposure to the thermal agent.

Upon contact with an incandescent object, steam or hot liquid, immediately stop the damaging effect. If clothes caught fire from an open flame, they douse them with water, throw in a tarpaulin or blanket.

Cool the affected area.

After thermal exposure, it is recommended to cool the burnt tissue (cold water, snow, ice). This event reduces the temperature of the tissues and weakens the damaging thermal effect.

Clothing should not be removed from the burnt area, it should be cut open and carefully removed . At the pre-medical stage , clothing adhering to the burn is not removed before dressing is applied, the blisters are not pierced.

First aid for electrical burns

Electrical burns are characterized by sooting and metallization of the burnt areas due to the combustion of conductor particles. Electrical burns are often combined with thermal burns due to the ignition of clothing.

If the skin is damaged by electricity:

Stop the electric current.

Disconnect the device or wire from the power supply, discard the conductive wires from the victim, pull them away from the exposed wires. The person providing first aid must take care of his own safety. Before performing the manipulation of de-energizing, it is necessary to wrap your hands with a dry cloth, stand on a board, rubber mat or any other object that does not conduct electricity 1 .

After isolating the victim from the power source, if necessary, perform artificial respiration and chest compressions . Place a cotton swab with 10% ammonia solution 1 up to the victim’s nose.

Cover the burned area with a sterile dressing.

First aid for chemical burns

As soon as possible remove clothing soaked in an aggressive substance.

Wash the affected area.

For 10-15 minutes, the affected areas are washed with plenty of running cold water. If the contact of the chemical with the skin lasted for some time, then the washing time is increased to 40 minutes.

Neutralize chemicals.

For acid lesions, use a 2-3% solution of sodium bicarbonate (baking soda), for exposure to alkalis, use a 2-5% solution of acetic or citric acid.

Apply dry aseptic dressing to the lesions.

First aid for sunburn

First aid for sunburn consists of applying soothing and healing agents to the skin. If blisters occur, wet-dry dressings with tannin solution or oak bark decoction can be recommended 2 . Dermatologists also recommend taking allergy medications (antihistamines) 2 .

Treatment of burns

To determine the tactics of treatment and predict the recovery of affected tissues except cause of burn must be determined:

  • Depth of injury . To do this, evaluate the condition of the skin. Redness of the skin and blisters are interpreted in favor of II degree burns.
    Absence of pain when pricked with a needle, pulling out hair, touching the burn site with an alcohol-containing substance, absence of “play of capillaries” after pressing with a finger – in favor of severe damage, not less than III-a degree.
  • Damage area . Doctors in practice use the “rule of nines” and “palms”. So, the head and one upper limb make up 9% of total body surface. One lower limb, anterior and posterior surfaces of the body 18% each, genitals and perineum 1%. According to the “palms” rule, the entire surface of the body can be measured with the palms, taking the size of 1 palm as 1% of the total body area.
  • On the basis of the depth and area of ​​the injury, doctors calculate an index of injury severity .

Severe burns should be treated in a hospital, burn unit.
In some cases, primary surgical treatment is required to remove dead tissue, transplant a skin flap.

Algorithm for the treatment of minor burns and wounds in a child. Watch a short video with surgeon Fyodor Yanovich Kraskovsky.

Treatment of burns at different stages of healing

During the restoration of burned skin, the same processes occur
as during the healing of any wounds: the stage of inflammation, regeneration,
maturation (epitalization and reorganization of the scar).

Phases of burn healing

For the treatment of first degree burns, soothing creams and ointments containing dexpanthenol and tannin are used. Healing occurs in a few days.

Burns, starting from the II degree of severity, are susceptible to infection, because the skin barrier is broken. For the treatment and prevention of wound infection, antiseptic agents are prescribed.

Inflammatory phase

The choice of antiseptic preparation for the treatment of burn wounds should be approached with particular care. The agent must have a broad antibacterial spectrum of action, be safe when applied, and not cause burning or pain during processing.

For this purpose, since the 1970s, povidone-iodine preparations have been used, which have antibacterial, antifungal and antiviral effects 4.7 . Iodine in combination with povidone does not cause tissue burning when applied even to open wounds. The use of povidone-iodine solution and ointment for superficial injuries leads to rapid and high-quality wound healing without significant inflammation and infection 5 .

Based on povidone-iodine for decontaminating wound surfaces 10% solution for external use Betadine ® and 10% ointment for external use Betadine ® .

Apply a thin layer to damaged skin several times a day. In the treatment of infected wounds under napkins soaked in solution or ointment Betadine ® , during the first 5-7 days, swelling and the amount of purulent discharge decrease, pain decreases 6 . Betadine ® solution and ointment are approved for use in children from the age of one month 7 .

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Povidone iodine

Characteristics and properties of povidone-iodine. What is povidone-iodine used for? Instructions for use of the solution, ointment, suppositories Betadine ® with povidone-iodine.

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Regeneration phase

Regenerating ointments and creams are used during the regeneration phase, for example, products based on lanthanum salts, water extract of wheat, dexpanthenol.

Maturation phase

The maturation of scar tissue occurs in the third phase of wound healing. Depending on the severity of the burn, scarring may remain. At this stage, to prevent the development of rough scars, it is recommended to use creams and gels based on silicone, hyaluronidase.

How to prevent burns in children

In children, burn injuries are more common before the age of 5 years 1 . Inquisitive kids can pull a pot of boiling water towards themselves, put their finger into a socket, touch a hot iron, pour or spray household chemicals. The high risk of burns in young children is associated with their inability to independently assess the danger of fire, hot liquids, chemicals.

Therefore, it is recommended that children have received a small child with 9000

  • unattended
  • in the room where young children are, use special linings on sockets that protect the fingers of curious babies
  • do not leave mugs, plates , pots, pans with hot contents in the immediate reach of children
  • cover heating radiators with protective covers
  • matches, lighters should be stored on the upper shelves
  • electrical appliances located on the worktops should be located away from the source of water
  • before feeding the child, check the temperature of cooked food children
  • children under 3 years of age should not be exposed to the sun without clothing. It is recommended to use sunscreens with SPF 50+

Frequently Asked Questions

What should not be done about a child’s burn?

  • Do not lubricate a fresh burn with oil or petroleum jelly, do not pierce the blisters, do not peel off clothing adhering to the burn. You can wash the burnt area with plenty of water.
  • Do not use sour cream, kefir or other folk remedies for sunburn. It is recommended to use special products, for example, with dexpanthenol.

Can blisters be punctured after a burn?

To prevent infection after a burn, it is better not to pierce the blisters yourself, but to consult a doctor to prescribe the correct treatment. If, nevertheless, the blisters burst, then the wound surface must be washed with a solution of chlorhexidine or treated with a solution of Betadine ® .

How long does it take for burns to heal?

Depending on the depth of the burn injury, the duration of healing will be different. With a first degree burn, the skin will recover in a few days.

For second-degree burns, if the wound does not become infected, the skin will heal within two weeks, and a temporary change in skin color (pigmentation) may remain.

With III and IV degree burns, healing can take up to 1.5 months or more. Usually there are scars and a violation of skin pigmentation.

Moshkova Elena Mikhailovna

Dermatovenereologist, Head of KDO for the provision of paid services, St.0003

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Polyvinylpyrrolidone (povidone)

Polyvinylpyrrolidone (povidone): application, use in the povidone-iodine complex.

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