A 28-year-old woman is brought to the emergency department 2 hours after her cotton saree caught fire while cooking. She has erythematous, blistering lesions over her anterior chest, abdomen, and bilateral upper limbs. The burned areas are painful to touch and blanch with pressure. Her vital signs are stable. Using the Rule of Nines, what is the approximate percentage of total body surface area (TBSA) burned?

## Surface Area Calculation Using Rule of Nines ### Rule of Nines in Adults The Rule of Nines divides the body surface into segments of 9% (or multiples thereof): - Head and neck: 9% - Each upper limb (arm + forearm + hand): 9% - Anterior trunk (chest + abdomen): 18% - Posterior trunk (back + buttocks): 18% - Each lower limb (thigh + leg + foot): 18% - Genitalia: 1% ### Calculation for This Case The patient has burns on: 1. **Anterior chest and abdomen** = 18% (anterior trunk = 18% total; chest = 9% + abdomen = 9%) 2. **Bilateral upper limbs** = 9% (right upper limb) + 9% (left upper limb) = 18% **Total TBSA = 18% + 18% = 36%** This is the straightforward application of the Rule of Nines as described in standard forensic medicine and surgery textbooks (Parikh's Textbook of Medical Jurisprudence; Bailey & Love's Short Practice of Surgery). ### Burn Depth Classification | Depth | Appearance | Sensation | Blanching | Healing | |-------|-----------|-----------|-----------|---------| | 1st degree (superficial) | Erythematous only | Painful | Yes, immediate | 3–7 days | | 2nd degree (partial-thickness) | Blistering, moist, red | Very painful | Yes, slow | 2–3 weeks | | 3rd degree (full-thickness) | Charred, leathery, white | Painless | No blanching | Requires grafting | | 4th degree | Charred muscle/bone | Painless | No | Requires grafting | **Key Point:** This patient has **partial-thickness (2nd degree) burns**, as evidenced by blistering, pain on touch, and blanching with pressure. These are the most common pattern in domestic saree-fire injuries in India. ### Clinical Management Implications **High-Yield:** A TBSA of 36% places this patient in the **major burn category** (>25% TBSA in adults). She requires: 1. IV fluid resuscitation using the **Parkland formula**: 4 mL × TBSA% × body weight (kg) over 24 hours 2. Immediate transfer to a burn centre 3. Tetanus prophylaxis 4. Analgesia and topical antimicrobial agents (silver sulfadiazine) 5. Nutritional support **Clinical Pearl:** The Parkland formula is calculated as: $$\text{Fluid (mL)} = 4 \times \text{TBSA\%} \times \text{Body weight (kg)}$$ Half is given in the first 8 hours (from time of burn); the remainder over the next 16 hours. Target urine output: 0.5 mL/kg/hr in adults. **Mnemonic for TBSA estimation:** **"Rule of Nines" = 9s and 18s** - Head = 9%, each arm = 9%, anterior trunk = 18%, posterior trunk = 18%, each leg = 18%, perineum = 1% ### Burn Centre Referral Criteria This patient meets multiple criteria for referral: - TBSA ≥ 15% (in adults) - Partial-thickness burns >10% TBSA - Burns involving the trunk and bilateral upper limbs [cite: Parikh Textbook of Medical Jurisprudence, 7th ed., Ch 8; Bailey & Love's Short Practice of Surgery, 27th ed.]