Burn Surface Area (Rule of Nines, %TBSA)
The Wallace Rule of Nines (1951) is the standard prehospital and ED tool for rapidly estimating burn surface area (total body-surface area, %TBSA). It partitions the adult body into multiples of 9 %: head and neck 9 %, each arm 9 %, anterior torso 18 %, posterior torso 18 %, each leg 18 %, perineum 1 % (sum = 100 %). Because a child has a proportionally larger head and smaller legs, a paediatric chart is used: age 5–14 → head 12 %, each leg 16 %; infant (< 5 yrs) → head 18 %, each leg 14 %. The tool also applies the Baxter / Parkland resuscitation formula (4 mL/kg × %TBSA of Lactated Ringer's over 24 h, half in the first 8 h) to recommend a fluid target — giving fire / EMS / ED staff a 30-second triage decision tool.
Total body surface area %TBSA
0%
Parkland fluid resuscitation (24 h)
Enter non-negative values for cash, expenses and revenue.
⚠ Estimation tool — for prehospital / ED triage. Final clinical decisions must be made by a qualified practitioner using a Lund & Browder chart and burn-depth assessment.
Formula
%TBSA = Σ (selected region percentages) ; Parkland 24-h fluid = 4 × weight(kg) × %TBSA mL of Lactated Ringer's ; half in the first 8 h, half over the next 16 h
- · Only second-degree (partial-thickness) burns and worse are counted. First-degree burns (sunburn-style red, no blisters) are NOT included in %TBSA and NOT used in the Parkland calculation.
- · For small or scattered burns (< 10 % adult / < 5 % paediatric) the "rule of palms" gives a finer estimate — the patient's own palm (fingers included) is approximately 1 % TBSA.
- · Rule of Nines is a screening estimate — for prehospital and initial ED triage only. Definitive clinical decisions require a Lund & Browder chart (age-stratified, more granular regions) and a burn-depth assessment.
- · ABA / ATLS burn-centre referral criteria: adult ≥ 20 % TBSA; paediatric ≥ 10 %; age < 10 or > 50 with 5–10 % burns; any face / hand / foot / perineum / major-joint / circumferential burn; inhalation injury; combined trauma or significant comorbidity — all warrant burn-centre transfer.
- · Parkland limitations: (1) it over-estimates fluid needs at very large TBSAs (> 60 %) — titrate to urine output (adult 0.5 mL/kg/h, paediatric 1 mL/kg/h); (2) paediatric and electrical burns may be better served by Cincinnati or Galveston formulas; (3) the "modified Brooke" formula (2 mL/kg/%TBSA) is now used in some centres to reduce over-resuscitation complications.
- · References: Wallace, A. B. (1951). "The exposure treatment of burns." *Lancet*; Baxter, C. R. & Shires, T. (1968). "Physiological response to crystalloid resuscitation of severe burns." *Ann NY Acad Sci*; ATLS Student Manual 10e Ch. 9; American Burn Association *Practice Guidelines for Burn Shock Resuscitation* 2008; NICE CG138.
Frequently asked
How does the Rule of Nines differ from the Lund & Browder chart?
They share the same goal — estimating %TBSA — but differ in precision and use case. The Rule of Nines (Wallace 1951) divides the body into eleven multiples-of-9 % regions and can be done in 30 seconds; it suits prehospital, fire-rescue and initial ED triage. Its weakness is paediatric error (an infant's head is ~21 % of TBSA, far above the 9 % of plain Rule of Nines). The Lund & Browder chart (1944) divides the body into 20+ regions with age-stratified percentages (head shrinks from 19 % at birth to 7 % at age ≥ 15) — used after admission for formal documentation, burn-centre planning and research. Standard practice: Rule of Nines on scene, then Lund & Browder for formal in-hospital reassessment. This tool uses Rule of Nines with a simplified paediatric adjustment, balancing speed and accuracy.
Why is the Parkland formula 4 mL/kg/%TBSA, and why is half given in the first 8 hours?
The Parkland formula was derived by Baxter at Parkland Hospital, Dallas (1968) from experiments on severe-burn shock recovery. Major burns leak large amounts of plasma through damaged capillaries (especially in the first 24 h), shrinking circulating volume and producing shock. Baxter measured that ~4 mL of Lactated Ringer's per kg per %TBSA over 24 h was the minimum effective dose that restores blood volume, renal perfusion and urine output. The "half in 8 h" rule reflects the highest capillary leak rate, which occurs in the first 8 h post-burn — fluid loss is fastest then. Over the next 16 h leak slows, so the infusion rate is halved. In practice urine output is the primary endpoint — adult 0.5 mL/kg/h, paediatric 1 mL/kg/h — adjust by 50–75 % if under target.
When should I refer to a burn centre?
American Burn Association (ABA), ATLS and NICE recommend burn-centre referral for: (1) partial-thickness burns ≥ 20 % TBSA in adults, ≥ 10 % in children / elderly (< 10 or > 50 yrs); (2) full-thickness (3rd-degree) burns ≥ 5 % anywhere; (3) burns involving face, hands, feet, perineum, major joints (knee, elbow, shoulder, hip) or circumferential burns — because of functional, cosmetic or airway implications; (4) chemical, electrical (especially high-voltage) or radiation burns; (5) inhalation injury (enclosed-space fire, facial soot, hoarseness, carbonaceous sputum); (6) burns plus trauma (fractures, head injury) or significant comorbidity (diabetes, CHF, immunosuppression); (7) paediatric or geriatric patients; (8) potential need for long-term rehab. This tool flags "Major burn — refer to burn centre" automatically when an adult is ≥ 20 % TBSA or a paediatric patient is ≥ 10 %.
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