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Difficulty: EasyTrauma and Burns

A 45-year-old man is brought to the emergency department after a propane tank explosion at his home. He is awake, alert, and complaining of severe pain. Physical examination reveals deep partial-thickness (second-degree) and full-thickness (third-degree) burns involving his entire posterior trunk and both of his entire upper extremities. There are also superficial (first-degree) burns involving his entire face and neck. The remainder of his body is unaffected. Based on the Rule of Nines, what is the estimated total body surface area (TBSA) percentage that should be used to calculate his initial fluid resuscitation requirements?

Answer: 36 %

Answer

36
According to the Rule of Nines for adults, the total body surface area (TBSA) is divided into multiples of 9%. The posterior trunk accounts for 18%, and each entire upper extremity accounts for 9%. The calculation for this patient's deep burns is therefore 18% + 9% + 9% = 36%. First-degree burns (superficial burns), such as those on the patient's face and neck, cause erythema and pain but do not lead to clinically significant systemic fluid shifts; therefore, they are always excluded from the TBSA estimate used for fluid resuscitation calculation.

Step-by-Step Solution

1
Identify the extent of clinically significant burns requiring fluid resuscitation.
Deep partial-thickness and full-thickness burns are located on the posterior trunk and both upper extremities.
Only second-degree (partial-thickness) and third-degree (full-thickness) burns are included in the TBSA calculation for burn fluid resuscitation.
2
Calculate the TBSA for the posterior trunk.
The entire posterior trunk accounts for 18% of the TBSA.
According to the adult Rule of Nines, the entire trunk is 36%, with the anterior portion being 18% and the posterior portion being 18%.
3
Calculate the TBSA for both upper extremities.
The two upper extremities account for 18% of the TBSA (9% for the right arm + 9% for the left arm).
According to the adult Rule of Nines, each entire upper extremity represents 9% of the total body surface area.
4
Evaluate the burns on the face and neck.
The face and neck are excluded from the TBSA calculation.
The face and neck only have superficial (first-degree) burns, which are never included in the Parkland formula or general fluid resuscitation TBSA calculations.
5
Sum the relevant percentages to find the final TBSA.
18% + 9% + 9% = 36%.
Adding the clinically significant regions provides the total TBSA to be used in fluid resuscitation formulas.

Key Concept

Rule of Nines and exclusion of first-degree burns in TBSA calculations
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Topics

Trauma and Burns

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