The rule of nines is a standardized method used to quickly assess how much body surface area (BSA) has been burned on a patient. This rule is only applied to partial thickness (2^nd degree) and full thickness (3^rd degree) burns. The diagram below depicts BSA percentages for adults and infants of one year or less. For children over the age of one year, please see the formula below.

For children over the age of one year, for each year above one, add 0.5% to each leg and subtract 1% for the head. This formula should be used until the adult rule of nines values are reached. For example, a 5-year old child would be +2% for each leg and -4% for the head.

An alternative method to calculating the BSA is to compare it to the size of the patient’s palm, which equates to approximately 1% BSA. For example, if a burn area is the size of (5) palm surfaces, the burn would be roughly 5% BSA. This method can be used to estimate the BSA for both adults and pediatrics. In most cases, you may find it more useful to use the rule of nines when evaluating larger burn areas and the “palm” method for smaller burn injuries.

Burns are classified as superficial (1^st degree), partial thickness (2^nd degree) or full thickness (3^rd degree) depending on the depth of the injury. For the most part, burns can be quickly classified during the initial assessment or primary survey and a more detailed evaluation can be conducted during the focused history and physical examination.

Superficial (1^st Degree)

Epidermis

• The skin will appear red without any blisters.
• The area will be painful and tender.

Partial Thickness (2^nd Degree)

Epidermis, Dermis

• The skin will appear red or white with blisters.
• The area will be severely painful.

Full Thickness (3^rd Degree)

Epidermis, Dermis, Subcutaneous Fat, Muscles

• The skin will appear leathery and dark brown to black.
• The inner area will not be painful, but the outer edges will be.

A seizure is a sudden change in brain function due to a massive electrical discharge in a group of nerve cells. The increased electrical activity will typically cause an altered level of consciousness and various changes in behavior, such as convulsions, automatisms, or a blank stare.

Types of Seizures

• Generalized Tonic-Clonic (Grand Mal): This is the most common type of seizure. The patient will experience a loss of consciousness followed by muscle rigidity and convulsions.
• Simple Partial: This seizure is sometimes referred to as a focal motor or Jacksonian motor seizure. The patient will remain conscious and have uncontrolled muscle spasms in one area of the body. The seizure activity might spread to another area of the body and it’s important to document the progression. This information is useful for identifying the cause and will help with long-term treatment.
• Complex Partial: This seizure is sometimes referred to as a psychomotor or temporal lobe seizure. The seizure usually starts with a blank stare, followed by an automatism such as lip smacking, chewing, rolling of the fingers, fidgeting or some other repetitive movement. The patient will appear dazed and will not to respond to any commands.
• Absence (Petit Mal): This seizure is most commonly seen in children where they experience an abrupt interruption of activity and stare blankly. The seizures only last a few seconds and can occur several times a day.
• Febrile: This seizure is most commonly seen in children, typically 6 months to 6 years of age, and is caused by a high fever. Approximately 5% of children with a fever will have a febrile seizure. The patient will experience a loss of consciousness followed by muscle rigidity and convulsions.

Stages of Seizures

• Aura: A sensation the patient experiences which serves as a warning that a seizure is about to occur. For example, this could be a sound, a feeling of anxiousness or dizziness, an odor, an odd taste, or an uneasy feeling in the stomach.
• Tonic Phase: The patient becomes unresponsive and their muscles tense up (muscle rigidity). This phase lasts approximately 15-20 seconds.
• Hypertonic Phase: The patient has extreme muscular rigidity with hyperextension of the back. This phase lasts approximately 5-15 seconds.
• Clonic Phase: The patient has convulsions and might suffer from oral trauma or incontinence. Their breathing might be shallow or absent. This phase lasts approximately 30 seconds to 5 minutes.
• Postictal State: This is known as the recovery phase. The patient is initially altered, confused or disoriented and their mental status improves over time. The patient typically feels exhausted and weak from the convulsions and might complain of a headache. This phase lasts approximately 5-30 minutes (sometimes several hours).

Common Causes of Seizures

• Hypertension
• Fever
• Poisoning
• Infection
• Hypoglycemia / Hyperglycemia
• Head injury
• Hypotension
• Stroke
• Hypoxia
• Eclampsia
• Drug or alcohol withdrawal
• Dysrhythmias
• Electrolyte imbalance

A patient who experiences seizures lasting longer than 10 minutes or has consecutive seizures without a period of responsiveness between them is considered to be in status epilepticus. This is a severe medical emergency and will require proper airway management, positive pressure ventilation and immediate transport.

The table below shows the most common causes of abdominal pain that EMT’s and Paramedics encounter in the field. It also specifies which abdominal quadrants and areas of the body might be painful to the patient. If you would like to make a correction or suggestion, please contact us.

	RUQ	LUQ	RLQ	LLQ	Epigastric	Midline	Diffuse	Flank	Shoulder	Back
AAA
AMI
Aortic dissection
Appendicitis
CHF
Cholecystitis
Diabetes
Diverticulitis
Ectopic pregnancy
Endometriosis
Esophageal disease
Gastric ulcer
Gastritis
Gastroenteritis
Heartburn
Hepatitis

	RUQ	LUQ	RLQ	LLQ	Epigastric	Midline	Diffuse	Flank	Shoulder	Back
Hepatomegaly
Hernia
Herpes zoster
Intestinal obstruction
Ischemic bowel
Kidney stones
Ovarian cyst
Pancreatitis
Pericarditis
Peritonitis
PID
Pneumonia
Pyelonephritis
Sickle cell crisis
Splenic rupture
UTI

There are three different types of abdominal pain: visceral pain, parietal pain and referred pain. The type of pain varies depending on the organ involved.

Visceral Pain

Visceral pain is directly related to the organ involved. The majority of organs do not have an abundance of nerve fibers, so the patient might experience mild or less severe pain that is poorly localized. It’s important to understand this does not mean the patient is experiencing a mild or less severe condition.

Characteristics:

• Less severe pain
• Poorly localized
• The pain is usually dull or aching and constant or intermittent

Parietal Pain

Parietal pain occurs when there is an irritation of the peritoneal lining. The peritoneum has a higher number of sensitive nerve fibers, so the pain is generally more severe and easier to localize. The patient will typically present in a guarded position with shallow breathing. This minimizes the stretch of the abdominal muscles and limits the downward movement of the diaphragm, which reduces pressure on the peritoneum and helps ease the pain.

Characteristics:

• More severe pain
• Easily localized
• The pain is usually sharp, constant and on one side or the other

Referred Pain

Referred pain is visceral pain that is felt in another area of the body and occurs when organs share a common nerve pathway. For this reason, it is poorly localized but generally constant in nature. An example is a patient with liver problems that experiences referred pain in the neck or just below the scapula.

Characteristics:

• Poorly localized
• The pain is usually constant

Review the most common causes of abdominal pain that EMT's and Paramedics encounter in the field.