Assessing Burns and Planning Resuscitation: The Rule of Nines
The first step in assessing a burn and planning resuscitation involves a careful examination of all body surfaces. A standard Lund-Browder chart is readily available in most emergency departments for a quick assessment of total body surface area burns. If this is not available, the "rule of nines" is fairly accurate in adult patients.
See the rule of nines as follows. Note that a patient's palm is approximately 1% TBSA and can be used for estimating patchy areas.
- Head/neck - 9% TBSA
- Each arm - 9% TBSA
- Anterior thorax - 18% TBSA
- Posterior thorax - 18% TBSA
- Each leg - 18% TBSA
- Perineum - 1% TBSA
With pediatric patients, the head is a proportionally larger contributor to body surface area (BSA), while the upper legs contribute less. This difference is reflected in the slight differences noted in the pediatric Lund- Browder diagram. A useful tool for estimating BSA of spotty burns is the close approximation of just less than 1% BSA to the patient’s palm size. Only second-degree burns or greater should be included in the TBSA determination for burn fluid calculations.