Lund and Browder Chart for Burn Assessment
The Lund-Browder chart is the recommended standardized method for calculating total body surface area (TBSA) burned in both adults and children, and it is particularly essential in pediatric patients because it accounts for age-related variations in body proportions. 1, 2
Why Lund-Browder is Superior in Pediatric Patients
- Children have proportionally larger heads and smaller lower extremities compared to adults, making the Rule of Nines inaccurate and prone to significant errors in this population. 1
- The Lund-Browder chart adjusts body surface area percentages based on age, providing the most accurate TBSA quantification available for all age groups. 1, 3
- The hand (including wrist) represents approximately 2.5% TBSA in adults but varies by age in children, highlighting why age-adjusted charts are critical. 1
How to Use the Lund-Browder Chart Correctly
- Record the extent of epidermal detachment separately from erythema on the body map—the amount of epidermal detachment, not erythema, has prognostic value for mortality risk. 1
- Detachment should include both already-detached epidermis AND detachable epidermis (Nikolsky-positive areas). 1
- Perform repeated assessments during the first hours of care, as initial TBSA estimates are frequently inaccurate (overestimated in 70-94% of cases). 1, 2
Alternative Methods When Lund-Browder is Impractical
- The entire palmar surface of the hand (palm plus fingers) represents approximately 1% TBSA, while the palm alone represents only 0.5% TBSA—this can be used for quick field estimation. 1, 2
- The serial halving method or open hand method can be used when the Lund-Browder chart is unavailable, though these are less accurate. 1
Digital Tools to Improve Accuracy
- Smartphone applications such as FireSync EMS, 3D Burn, or EasyTBSA can facilitate more accurate TBSA calculation and reduce overestimation bias compared to manual methods. 1
- FireSync EMS significantly reduced overestimation bias (0.11% vs 0.91% with Lund-Browder) and was particularly superior for burns on child-size patients and burns involving <10% or >20% TBSA. 4
- The 3D Burn application under-estimated burns by only 1.9% on average, compared to Lund-Browder chart overestimation of 8.3%. 5
- EasyTBSA had the greatest accuracy (-0.01%, SD 3.59%) compared to Lund-Browder Chart (4.42%, SD 5.52%) across all age groups and burn sizes. 6
Critical Pitfalls to Avoid
- TBSA is overestimated in 70-94% of cases, leading to excessive fluid administration—be conservative in your estimation. 1, 2
- Never use the Rule of Nines for children, as it fails to account for their body proportions and significantly overestimates TBSA. 1
- Do not rely on erythema alone for TBSA calculation in severe burns—measure actual epidermal detachment for accurate prognostication. 1
- Pediatric patients are particularly prone to overestimation, which can lead to over-resuscitation and fluid overload. 7
Clinical Integration
- The Lund-Browder chart should be used before calculating the revised Baux score for mortality prediction and determining need for burn center transfer. 3
- Accurate TBSA calculation guides fluid resuscitation requirements (20 mL/kg of balanced crystalloid for adults with burns >15% TBSA and children with burns >10% TBSA within the first hour). 2
- Children with TBSA >10% or deep burns >5% should be referred to a burn center. 2