Riverbend EMS

Burns (Rule of Nines)

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This page consist of online training for EMS personnel.  The subject of training is "Burns and the Rule of Nines".  To see more training topics,   Click Here!

One of the most painful injuries that one can ever experience is a burn injury.   When a burn occurs to the skin,  nerve endings are damaged causing intense feelings of pain.   Every year,  millions of people in the United States are burned in one way or another.   Of those,  thousands die as a result of their burns.   Many require long-term hospitalization.   Burns are a leading cause of unintentional death in the United States,  exceeded in numbers only by automobile accidents and falls.

Serious burns are complex injuries.   In addition to the burn injury itself,  a number of other functions may be affected.   Burn injuries can affect muscles,  bones,  nerves,  and blood vessels.   The respiratory system can be damaged,  with possible airway obstruction,  respiratory failure and respiratory arrest.   Since burns injure the skin,  they impair the body's normal fluid/electrolyte balance,  body temperature,  body thermal regulation,  joint function,  manual dexterity,  and physical appearance.   In addition to the physical damage caused by burns,  patients also may suffer emotional and psychological problems that begin at the emergency scene and could last a long time.

Most burns can be recognized during the initial assessment of the patient.   Certain interventions may be started prior to arriving at the receiving facility.   Burns are classified by their depth.    The seriouness of a burn can be evaluated by both the depth of the burn and the percentage of body surface area  (BSA)  involved.   As with any other enviromental emergency,  the elderly,  the sick,  and children are less likely to be able and cope with burns.   Other factors would include,  trauma such as Head Injuries,  Spinal Injuries,  Fractures,  or patient's with any other underlying medical condition(s).   These patients' should be managed aggressively.

We will not be covering the management of burns on this page.    You should always follow your local Treatment Protocols and/or Standing Orders when providing treatment for any patient in any given emergency.   We will only be presenting the Classifications of Burns,   The Body Surface Area or percentage of burns  (BSA),  the Rule of Nine's with a diagram of how to utilize the Rule of Nines,  and we will cover the Parkland Burn Formula.   This page is not intended to take place of your local Treatment Protocols and/or Standing Orders,  it is merely written in order to help assist with the understanding of the burn patient.   If you have any questions pertaining to the burn patient,  or suggestions on how to improve this page,  please feel free to E-mail us.

There are four major sources of burn injurues:

  • Thermal Burns, also called heat burns:
  • Electircl Burns:
  • Chemical Burns:
  • Radiation Burns:


Type Source
Thermal Hot liquids, solids, super-heated gases, flames
Electrical Low or high-voltage current, lightening etc.
Chemical Wet, dry, or corrisive substances
Radiation Ultraviolet light, (sunburns), atomic explosion

Lightening injuries are also considered to be electrical burns.   The amount of damage caused by electrical burns is determined by the type of current,  duration of current,  voltage and amperage of current,  resistance of the tissue,  and the path the currents follows through the body.   This damage is actually caused by the generation of heat.    As the current of electricity flows through the tissue,  heat is generated by the resistance of the tissue.   Effects of an electrical burn can cause damage to the body as well.   Fractures could occur from severe muscle contractions.   Consideration should be given to the spine,  this is a common area of injury from electrical burns due to the violent muscle contractions.   Passage of high-voltage electrical current through the heart can disrupt the normal electrical activity of the heart and result in asystole,  ventricular fibrillation,  and even death.   Respiratory Arrest may also occur if the passage of current includes the brain.


Type How they occur
Contact burns Passage of electrical current through the tissue. A charred entrance and exit wound may be seen. Most damage is internal.
Arc burns Arching of electricity between two contact points of the skin. The electricity exits and reenters the skin looking for the shortest pathway. Flexed joints are common injuries.
Flame or flash burns These occur when to close to an electrical source and clothing ignites. The result is a thermal burn.
Lightening burns. Caused by lightening strikes with many thousands of volts that take a fraction of a second to strike the ground.


Type of Burn Skin Involvement Symptoms Appearance
Superficial (First Degree-Burn) Sunburn, Low-intensity flash etc. Epidermis Tingling, painful, soothed by cooling Reddened, blaches with pressure, minimal or no edema
Partial-Thickness (second degree) Scalds, Flash flames etc. Epidermis and part of the dermis Painful, sensitive to cold air Blistered, mottled red base, broken epidermis, weeping surface, and edema
Full-Thickness (First-Degree) Fire, prolonded exposure to hot liquids etc. Epidermis, entire dermis, and sometimes subcutaneous tissue and even bone Painless due to nerve damage, may be symptoms of shock, Hematuria and hemolysis of blood could occur Dry, pale white or grey charred skin, broken skin with tissue exposed, and edema


Depth of the burn: Deterimined by the depth of tissue involved, the greater the depth, the more severe the burn.
The extent of the burn: Determined from the Rule of Nines or other calculation methods. The larger the extent, the more severe the burn.
The location of the burn: Burns of the face, hands, neck, perineum, and feet, even if small burns, can become debilitating.
The age of the patient: The age of the patient is important in determining the outcome, infant children, and the elderly are seriously affected by severe burn injuries.
The patient's general health: The underlying health of the patient plays a major role. Diabetes, hypertension, cardiac or pulmonary diseases can often increase mortality rates or complicate the condition of the burn patient.
Any associated injuries, i.e. trauma etc. Fractures or internal injuries can complicate a burn injury, this type of complication could be caused by an explosion, Motor Vehicle Accident or from fires associated with falls.

Body Surface Area:

The degree of Body Surface Area  (BSA)  involved in burns in the pre-hospital setting are normally measured utilizing the Rule of Nines.   The human body can be subdivided into segments that would account for approximately 9% of the total BSA.   Utilizing the rule of Nines,  one can combine the regions of the body,  or portions of the body and come up with an effective estimation of the percentage of BSA involved.    For smaller or for less extensive burns,  the hand can be used for a rapid measurement.   The adult hand would cover approximately 1% BSA of their body.  i.e.  a burn area about the size of three adult hands would equal about 3% of the entire BSA.   One must remember, in the infant or child,  the percentages remain the same with the exception of the head,  the head in the infant or child is 18%,  this is due to the head being larger in porportion to the body than the adult.   See the example chart below to estimate the BSA involved utilizing the Rule of Nines.

The Rule of Nines

Inhalation Injuries:

Suspicion of inhalation injury should never be ruled out.   Inhalation injuries require immediate and intensive therapy.    This type of injury more often than not occurs from steam or toxic fumes.    Patient's surrounded by smoke and fire in a closed space are common candidates for an inhalation injury.   These types of injuries account for more than half of burns deaths that occur every year according to statistics.

Smoke Inhalation:

Smoke inhalation damages the lungs,  it is caused by products of incomplete combustion.   These products are toxic to airway mucosa , this is due to excessive acidity.   The results are severe inflammation,  congestion,  and possibly marked pulmonary edema.    It is a possibility that signs and symptoms could be delayed for as long as twelve to thirty six hours.   Usually,  the sooner the signs and symptoms appear,  the more severe the damage.   Some of the signs and symptoms are,  hoarseness,  cough,  carbonaceous sputum,  singed nasal hair,  blisters around the mouth,  labored or rapid breathing,  and facial burns.

Carbon Monoxide:

This type of injury occurs when a patient is trapped in close quarters,  i.e.  a closet or small room with poor ventilation.   The fire consumes all of the available oxygen and Carbon Monoxide would be the product of incomplete combustion.    Carbon Monoxide is a colorless,  odorless,  and tasteless gas.   It passes through the lungs and combines with the Hemoglobin to produce Carboxy-Hemoglobin.   Since the carbon monoxide has an affinity for for hemoglobin 200 times greater than that of oxygen,  the carbon monoxide displaces the oxygen.   The largest component of damage occurs at the Cellular level in the Mitochondria.   Early signs and symptoms would include headache,  nausea,  vomiting with loss of manual dexterity.   Moderate levels of posioning produces confusion,  lethargy,  and depressed ST segments.   Late signs are pink color skin,  and muscous membranes with a cherry red color.   Eventually death will occur if not treated aggressively.    The Hypoxia that results from carbon monoxide posioning is caused by a decrease in circulating oxygen and may result in permanent or recurring Central Nervous System damage.

Chemical Burns:

This type of burn differs from a Thermal burns in that the topical agent sticks to the skin.   Flushing should begin immediately with copious amounts of water.    Neutralizing should be avoided since this could cause an additonal reaction.   Considerations should be paid to chemicals irritants such as dry lime.   This should be brushed off as much as possible and all clothing should be removed,  then one can proceed with the flushing process.   See the below chart for additonal information regarding chemical burns.   And please be sure to always follow your local Medical Protocols and/or Standing Orders.


Carbolic Acid (Phenol) Rinse with alcohol if possible before flushing with water.
Dry Lime Brush away as much as possible before flushing with water, be sure to remove clothing.
Hydrofluoric Acid Flush with copious amounts of water for a minimum of 15 minutes. Remove all contaminated clothing and administer 100% oxygen.
Lye Do no induce vomiting if ingested. Flush with copious amounts of water if external.
Sulfuric Acid Rinse with soapy solution if possible before flushing with water.


We hope this page was helpful in understanding the burn patient, as stated above, we "do not" provide treatments on our site, your local Medical Protocols, or Standing Orders should always be utilized.  If we can be of any assistance, please E-mail us, we are always happy to hear from you.

This Site Designed and Maintained by: Lee Sampson/Flight Paramedic
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