The first step in burn wound assessment is to evaluate the extent of burn. Burn injuries are expressed as a percentage of the total body surface area (TBSA). It is important to estimate the TBSA involved so that fluid resusitation calculations can be made, the magnitude of the physiological response can be estimated and the severity of the injury can be determined. According to Carrougher, (Burn Care and Therapy, 1998, Mosby ) the three basic methods of determining the extent of a burn are:

1. Rule of Nines: Introduced in the 1940s by Pulaski and Tennison as a quick assessment took for determining the size of a burn injury. Often used in pre-hospital settings or in the ED to obtain a general estimate of the extent of the burn. Based on the presumption that the body can be divided into nine anatomic regions that represent 9% of the entire body surface. It is reasonably accurate in individuals 9 years of age and older. However, in infants and children, the rule of nines calculation is different because of the relatively larger surface area of the head and the smaller area of the lower extemities.

2. Burn Diagrams.Use of burn diagrams with age-dependent calculations. These are generally more precise than the rule of nines because the diagram percentages are calculated on much smaller body segments and are age specific. (The Lund and Browder Chart is available in most emergency departments for use in estimating burn area in children and is used for additional accuracy in adults.)

3. Rule of the Palm. This method used the patient's hand-size to estimate the percent TBSA of small burns. The palmer surface of the hand (palm and fingers) equals roughly 1% TBSA in all age groups.

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