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446 AClJT£ CARE HANDBOOK FOR PHYSICAL THERAPISTS

formula is quick and easy to use, especially when a rapid initial estimation of TBSA is needed in the field or the emergency room. To use the rule of nines, the area of burn is filled in on the diagram, and the

percentages are added for a TBSA. Modifications can be made if an

entire body section is not burned. For example, if only the posterior

left arm is burned, the TBSA is 4.5%.

Lund and Browder Formllia

Table 7-4 describes the Lund and Browder formula. The body is

divided into 19 sections, and each is assigned a different percentage of TBSA. These percentages vary with age from infant to adult to accommodate for relative changes in TBSA with normal growth.

The Lund and Browder formula is a more accurate predictor of

TBSA than the rule of nines because of the inclusion of a greater

number of body divisions along with the adjustments for age and

normal growth.

Estimating the Extent of Irreglliarly Shaped Bllms

It is important to note that using the rule of nines or the Lund and

Browder formula may not be accurate for irregularly shaped

burns. To estimate TBSA with irregularly shaped burns, the

patient's palm is used to measure the shape of the burn. The palm

represents 1 % TBSA.'2

Assessing the Depth of a Burn

The depth of a burn can be described as superficial, moderate partial

thickness, deep partial thickness, or full thickness (Figure 7-5). Each

type has its own appearance, sensation, healing time, and level of

pain, as described in Table 7-5. The assessment of burn depth allows

an estimation of the proper type of burn care or surgery and the

expected functional outcome and cosmesis." Although clinical

observation remains the standard for burn depth estimation, there is

often error or underestimation. Experimental technologies for morc

precise burn depth estimation include cell biopsy, vital dyes, fluorescein fluorometry, laser Doppler flowmetry, thermography, ultrasound, and nuclear magnetic rcsonance.4

A burn wound is considered to be a dynamic wound in that it can

normally change in appearance, especially during the first few days. A

partial-thickness burn can convert to a full-thickness burn from infection, inadequate fluid resuscitation, or excessive pressure from dressings or spiints,I4

BURNS AND WOUNDS 447

Table 7-4. Lund and Browder Method of Assessing the Extenr of Burns'"

'1-4

5-9

10-14 15

Birth

yrs

yrs

yrs

yrs

Adult

Head and trunk

Head

19

17

13

1 I

9

7

Neck

2

2

2

2

2

2

Anrerior trunk

13

13

13

13

'13

13

Posterior trunk

13

13

13

13

13

13

Left butrock

2.5

2.5

2.5

2.5

2.5

2.5

Right burrock

2.5

2.5

2.5

2.5

2.5

2.5

Genitalia

Upper extremity

Left upper arm

4

4

4

4

4

4

Right upper arm

4

4

4

4

4

4

Left forearm

3

3

3

3

3

3

Right forearm

3

3

3

3

3

3

Lef, hand

2.5

2.5

2.5

2.5

2.5

2.5

Righ' hand

2.5

2.5

2.5

2.5

2.5

2.5

Lower extremity

Left thigh

5.5

6.5

8

8.5

9

9.5

Right thigh

5.5

6.5

8

8.5

9

9.5

Left lower leg

5

5

5.5

6

6.5

7

Right lower leg

5

5

5.5

6

6.5

7

Lef, foo,

3.5

3.5

3.5

3.5

3.5

3.5

Right foot

3.5

3.5

3.5

3.5

3.5

3.5

·Values represent percentage of rota I body surface area.

Sources: Adapted from WF McManus, BA Pmin. Thermal Injuries. In DV Feliciano, EE

Moore, KL Matrox (cds), Trauma. Stamford, Cf: Appleton & Lange, 1996;941; and CC

Lund, NC Browder. The estimation of areas of bums. Surg Gynecol Obstct 1944;79:355.

Act/Ie Care Ma/wgemenl of Bt/rn In;t/ry

This scction discusses the admission guidelines and resuscitative and

reparative phases of burn carc.

Admission Guidelines

In addition to the burn's extent and depth, the presence of associated

pulmonary, orthopedic, or visual injuries determines what level of