EMS Burn Rule of Tens

Burn injuries are commonly encountered in the emergency department (ED). While burn injuries may be induced by chemical or electrical sources, friction, cold, heat, or radiation, most burn injuries are secondary to exposure to heat from hot liquids, heated solids, or fire. Most burn injuries occur in children aged 1 to 16 and adults aged 20 to 59. Fire-related burn injuries account for 41% of burns, while scald injuries account for 31%. Emergency medical services (EMS) should assess the extent and severity of burns through visual inspection and calculation of the affected total body surface area (TBSA) before commencing fluid resuscitation in the field.  In the United States, burns are the third most common cause of injury and mortality in children aged 5 to 9 years and the leading cause of death in children aged 1 to 14. The pediatric population is especially vulnerable to burn injuries; a severe burn in a pediatric patient is defined as greater than 10% TBSA affected. This sharply contrasts severe burns in adults, defined as 20% or more of TBSA affected.Burn injuries are especially dangerous due to distributive shock and the subsequent systemic inflammatory response. If inadequately treated, multiple organ failure may result. Severe burn injuries primarily affect the cardiovascular, gastrointestinal, renal, respiratory, and integumentary systems. EMS traditionally employs the "Rule of Nines" tool to assess the TBSA affected by burns in patients with second- and third-degree burns. The Rule of Nines assigns each body part a percentage, usually 9%, or a multiple thereof 9 (see Diagram of the Rule of 9s for Adults). These percentages can be used to quickly calculate the affected TBSA in pediatric and adult populations (see Diagram of Rule of 9s Modifications for Pediatric Patients). The Parkland formula uses this estimated TBSA percentage to determine the appropriate total fluid resuscitation for patients with severe burns. The Parkland formula multiplies the patient's total body weight by 4 and multiplies that value by the affected TBSA to calculate the total required resuscitative fluid volume. The Parkland formula recommends administering half of the required fluid volume over the first 8 hours of resuscitation and the remaining half over the subsequent 16 hours. The Parkland formula is favored because it relies on visual estimates but is limited by approximating total patient body weight if that value is immediately unavailable. The "Rule of Tens" improves upon The Rule of Nines by simplifying the initial fluid resuscitation calculation. The only variable required is the affected TBSA rounded up to the nearest 10 (% TBSA x 10 = initial fluid rate in mL/h). The Rule of Tens was developed for combat prehospital providers needing a quick way to estimate resuscitation volumes for multiple burn victims in the field. The Rule of Tens aims to streamline the initial TBSA calculation and gradually reperfuse the patient, preventing any potential complications from volume overload.  The Rule of Tens eliminates the need for an exact patient weight if the patient falls within the 40 to 80 kg range. By removing the need for an exact weight calculation, EMS can use the Rule of Tens to initiate initial fluid resuscitation quickly. The Rule of Tens also permits adjustments to the rate of fluid resuscitation as the patient is stabilized; this is in contrast to the Parkland formula, which requires the administration of a total volume over 24 hours.