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Welcome the opinions expressed in this presentation of my own reflections and are not to be construed as official UK defense medical services policy, we're going to go through the management of burn injury. So the majority of birds that we see in conventional battles aren't as a primary result of the weapon exploding. It's from a secondary ignitions having said that there are specific weapons that are designed to cause fire, but the impact on the incidence of burns has not been quantified and these weapons they are lawful if used against military targets. And for example, got flamethrowers, things like napalm. This is a peculiar element where the, the legality of it is dubious. And then we have something called enhanced blast weapons or frova barrack explosives loose to get called vacuum bombs. These do generate more heat, they are not unlawful. We've not actually seen any reports suggest that's an increase in the number of burned casualties in survivors because of these weapons. It may just be that we get more burned deaths from it. But another big thing to remember, it's not just the military aspect of burns in conflict. You have an alteration in normal society and behavior changes and this increases the incidence of burns and Children are unfortunately disproportionately affected. You do find soldiers will do stupid things which will leave them liable to saying burn injury. But if that was your kitchen and you can no longer live in your house because of the conflict and you end up having to resort to cooking over an open fire outside and there are Children running around. This does lead to a greater number of burn injuries in the civilian population. Before you do start getting involved in any form of treatment, particularly in conflict situations, you have to establish in your own mind, the context in which you are providing that care. And there's the list there that you have to go through a checklist. Basically, it's to find out where you fit in the patient pathway because unless you know exactly where you are in the overall situation, it's difficult for you to embark on what would be the appropriate forward burned care. So you need to understand not only what can be done, but you should make an assessment of what should be done in the particular location and environment in which you are and in a conflict situation that may change very often, you might certainly find that you have an expectation of doing some initial burn care. But all of a sudden the patient, you expected to be moved on within 24 hours to a place where they've got burned care specialists that evacuation route may no longer be available to you and you may have to hold that patient for five, five days and then maybe embark on specific burn care. That's not normally within your area of specialization might suddenly find that you have an expectation of doing some initial burn care. But all of a sudden, the patient, you expected to be moved on within 24 hours to a place where they've got burned care specialists that evacuation route may no longer be a available to you and you may have to hold that patient for five days and then maybe embark on specific burn care that's not normally within your area of specialization. And before we talk about how you would manage a bird, we do have to just mention a little bit of patho physiology to put it all into context. And there are three main elements to managing a burn. There's the actual burn to the skin itself, there's the systemic effect that has on the rest of the body. And then there's an inhalation injury as well if you have a burn, that is quite superficial and it involves just the epidermis and the top layers of the dermis because there are these epidermal elements going deeper down. That's a reservoir of epithelial cells that can rejoice generate across the top. So superficial burn can heal quite nicely by itself. If the burn is deeper and you lose a lot more of the dermis and those epithelial reservoirs, then the burn will take a lot longer to heal and you'll get much more scarring. So, understanding the depth of the burn does dictate the way you will manage that burn wound later, the systemic effects. If you get a volume of heat, damaged tissue that stimulates the cytokine cascades and initiates inflammation once the burn is over a certain size and that does vary but certainly anything above 30% maybe there's 20% that inflammation is systemic. The whole body becomes inflamed and the consequences of that needs to be managed. And also if you have a concomitant inhalation injury and your initial resuscitation is not effective. The ongoing drive for that systemic inflammatory response becomes much worse. And briefly, to mention inhalation injury, there are three main components to the inhalation injury, firstly to the upper airway and that is a true thermal burn. So when your upper airways actually get heat damaged, and uh obviously, they're the consequence of that is swelling, damage to the lower airways, that is mainly a chemical injury. So it's the products of combustion, the smoke actually causes a chemical injury to the lung tissue itself. And finally, with inhalation injury, you could absorb some of those products of combustion which actually then poison you. And the classic examples of that are carbon monoxide and cyanide. First thing you need to do is to actually stop the burning process. So remove the source of the heat and then actually cool the tissue that is still being burned down by whatever means is appropriate. There is evidence now that actually carrying on the cooling the burn for a period of time does reduce the overall inflammation. The exact length of time that that needs to go on for is debated but certainly for about 20 minutes to half an hour carrying on cooling the burn after the initial burning processes stopped is beneficial. But at the same time, he was make sure the patient doesn't get too cold. So there is a balance to be struck there. Once you're happy with that, then from a first eight point of view, you just need to provide some sort of cover of the burn because exposed burn tissue is painful and also because it's painful give analgesia. Now there are commercially available burns dressings, but we do not advocate their use particularly in the military environment. They do tend to make the patient's a lot colder. They are quite heavy to carry around and there is no sort of proven benefit of their use. So they are no better than using simple car cold water or cool water to cool the burn down and then covering with something like cling filled. If you do think you're dealing with what a large burn, then you can in a pre hospital environment, start some intravenous fluids. And here a guide is what is known as the rule of tens. So you roughly estimate the size of the burn and then you multiply that by 10 and that gives you a new number which tells you the mils per hour of crystalloid you can give them. Now, this works for average sized people of fighting age. So for older people or very large people or Children, then you would need to adjust that. Then once the person is in a formal medical facility, even a very small one, you then need to start with a structured initial assessment of the birth. And if you take the view that burn victims are trauma victims, that then that's a good start. And you go down the C A B C D E approach. So the see at the start is for catastrophic hemorrhage. And then there are traditional ABCDE approach. We'll make the assumption that there is no catastrophic hemorrhage and this is for a burn over 20%. So the first assessment with a, is there any possibility of an inhalation injury? You would look at that and say almost straightaway. Yes, there is a possibility there are burns around the face quite clearly and he's spitting are soot and coughing up some suit as well. Now, the possibility here is that over time that you may get facial swelling and that is the potential situation you could end up in. That will normally if it is going to happen, happen within the first few hours. But what you need to do is to make sure that the patient is intubated before the swelling happens. Because once that swelling is what established like this, it will be very difficult to get the tube down. Having said that in a military conflict environment, if every person who came in looking like that ended up being intubated just in case, then your entire evacuation chain would become saturated with people requiring critical care transfer with tubes down. So you do have to exert some judgments and in a burn center of excellence. And we can see here in this picture here, we have four senior solicitous ts deciding what's the appropriate way of managing a potential burnt airway. And there was a surgeon scrubbed as well ready to perform a surgical airway. Now, there is no easy answer to the way to manage this and in a normal civilian setting, you would probably be very cautious and secured airway early in a military setting that could clog up your evacuation chain and often it may be more appropriate there to be more conservative and only intubate people if absolutely necessary. Once you have got an established airway, then it's a case of, can you actually get the gas is I/O of the lungs and is the pulmonary function satisfactory? Now, I mentioned about the lower airway chemical injury, the effects of that are normally delayed often by a day or two before they fully see the impact of it So in the initial management, the breathing element isn't hugely important as long as you can get air I/O. And with constricting chest burns, you may need to perform immediate escharotomy, knees to physically get air I/O of the lung through an intact airway. And then see for circulation, burn shock develops over several hours. So if the patient arrives quite early on after the injury at your facility and they are in shock hypovolemic shock, then it is more likely to be due to causes other than the bird, in particular hemorrhagic shock. So you do have to be very careful that you're not missing other injuries. And if they are shocked early, you treat that according to normal protocols, irrespective the cause you don't focus on the bird. If they have reduced neurological performance, ask yourself why is it because they're hypoxic? Have they got systemic intoxication from an inhalation injury or have you got other injuries you've missed? And even in battlefield environments, occasionally you do encounter drugs and alcohol abuse. So just just think about that environmental control hypothermia with burn injury is a very significant risk. Even in very warm environments, burns patient's get hypothermic very easily and we do use the adage to cool the burn but warned the patient and that can be challenging at times my preference that I would rather have a warm patient than a cold patient. So if it comes to it, don't make the patient hypothermic by calling the burn. Then the other initial intervention, analgesia burns are painful and distressing. So get plenty of analgesia on board as soon as possible. They will need for a larger burn and nasogastric tube and a urinary catheter. In normal civilian burn practice, we do not give prophylactic antibiotics, but in battlefield injuries, we assume there has been some, some contamination. Therefore, we've will give the normal antibiotics you would give for a battlefield injury. You need to make sure they are tetanus immune. And then having done all of that, you re assess the patient and perform a secondary survey. We can then move on to specific bird management. And this comes down to assessing the size of the bird injury. And from that, you can calculate some fluid requirements, you need to monitor the response to those fluids and pay attention to the wound itself. So how much is burnt? The impact on the systemic inflammatory response is related to the size of the burn. And this is expressed as the percent of the total body surface area burnt. The best way of calculating that is a London Browner chart. And you can see the example of it there, you can do a quicker assessment normally in the pre hospital environment where you just have a quick look and say, well, if, if you can see the front half of the body and half of that is burnt, that's 25% of the body and you just do this serial serial, having to give yourself an idea. But ideally use a London Browner chart and online there are mapping tools now which you can download to help with this. Having worked out how much has been burnt, then you can start to anticipate what are the likely fluid requirements? Because with burn tissue, with the large amount of inflammation, you get significant capillary leakage and you get loss of intravascular volume, which makes you relatively hype over Levick, which manifests itself as shock. So what you need to do is give additional intravenous fluids. But if you view these as prophylactic fluids to prevent bird shock, that's a good way of thinking about it. They normally get referred to as resuscitation formula, but resuscitation implies that the patient's already in shock and you're trying to catch up. It is better to give the fluids before they become shocked to prevent it. Now, for burns, less than 20% just giving patient's additional amounts to drink is normally enough. The only caveat I would say there is if you've got someone who's then going to be put in the back of an ambulance for a few hours and they've had some morphine, they're quite likely to go off to sleep and when they're asleep, they're not drinking. So they may still need to have intravenous fluids put up, but you don't necessarily have to give it as a formal formula. And there are many formula around to work out how much fluid you should give. You need to be aware that the need of this additional fluid starts at the time of injury. So if there is a delay in getting to medical care already, there may be some catch up required. But if you calculate that someone's maybe two liters behind, I wouldn't necessarily give that two liters in a single bolus as a catch up because you're quite likely then to overload the patient. So it may be sort of spread it out a bit. And these formula only act as a guide. If there are other reasons for fluid loss, such as other injuries causing bleeding, such as a fractured femur, then this fluid calculation doesn't include those additional losses. Well, I would suggest as a starting point would be to use two mils per percent burn per kilo. That calculation gives you a volume and that's the amount anticipated to reduce the chance of developing pern shock in the 1st 24 hours. And you give half that amount in the first eight hours and the second half in the following 16 hours. And this is based on a crystalloid intravenous fluid. And Hartmann's or lactated ringers is better than normal saline if you can. Now this is just a starting point and you'll see there'll be several formula which will advocate three or four mills in a more military environment where things aren't necessary under such tight control. Often it is easier if you're a bit behind with the fluids by starting lower to catch up with less detriment than it is if you give someone too much fluid and they end up being overloaded. But the way to keep an eye on this is to actually then monitor the physiological response to the amount of fluid that they are being given. And your target for an adult is half a mil per kilo per hour of urine and more than that for a child, but also keep an eye on the hematocrit and the user knees. But also very useful is to if possible track the blood gasses regular, in particular, looking at the lactate or probably more accurately the base excess to give you an idea about the overall fluid status of the patient. And it's worth noting that with a significant burn, the patient will be tachycardic and probably have a pyrexia as well. This is a normal part of a systemic inflammatory response to monitoring it. What that means as well. If it's not right, then you increase or decrease the rate of crystalloid infusion as necessary. It is quite well understood that if the urine output is low, that you increase the amount of fluids, what is done less well is if the urine output is very high, people seem reluctant to actually reduce the crystal infusion. But it is equally important. A useful marker is if after about the 1st 12 hours, the the urine output remains poor, but you've already got a high infusion rate and it's predicted you're going to be giving more than six mils per kilo per percent burn during that 1st 24 hours. That's a sign that you're getting into significant problems. And actually, when you reach that point, simply giving more crystalloid doesn't necessarily help matter. So certainly after the 1st 12 hours, if you are a long way behind, then it is now appropriate to give bolus is of colloid, preferably albumin and what's used to be considered very bad practice with burns but is now becoming more accepted. If you have significantly overloaded the patient, then you cautiously could administer some frusemide to help offload it. If we've reached the point where we are maybe having to give Pulis's of colloid or going the other way, start using frusemide. You can see we are entering into a situation where critical care support is required. Additionally, to these measures, I think it's important to make sure that energy tube is down and start feeding as soon soon as is possible. And in addition to the feeding, certainly after the 1st 24 hours, maybe after the 48 hours, you can also reduce the amount of fluid you're giving intravenously by increasing the amount of free water. You can put down the nasogastric tube, Children will need an additional formal maintenance fluid regime. In addition to the burns formula I've mentioned. And when you do start getting into more difficult critical care situations. In normal burn practice, peripheral vasoconstrictor zippers are frequently used and that's titrated against the mean arterial pressure. Most commonly in the UK nor epinephrine will be used. But that practice does vary from country to country. Also, the early use of beta blockade is advocated as long as you're not having to resort to visa constrictors. And the other thing to note that there is a high risk of venous thromboembolism in Bern patient's. And so if possible, they ought to be on blow molecular weight heparin. And then when it comes on to looking at the wound itself, unless you given the burn a thorough scrub, you can't assess it properly. So the first thing you need to do there is a, is a really thorough scrub, then assess the depth and burn, decide whether you need to do escharotomy knees and then to cover it with something. Now, ideally, the thorough clean and assessment should be done in a warm operating theater. But as you can see from this photograph, it's fairly labor intensive does take a lot of people to help turn the patient and to actually do the scrubbing, it's not a delicate little dab of, of a wound. It is a hard aggressive scrub. And you can see here coming off the patient onto the sheep there, that's the blisters. So this is a thorough scrub because without that, if you look at the picture on the left. You've got no real idea what's going on. It's not till you given that thorough clean that you can assess the true extent and the depth properly. Now, escharotomy, this, this is where you have constricting deep burns, particularly of the limbs and you need to release the deep burnt tissue to allow the natural swelling to develop. Because if you don't allow that, that the tissue will then increase in pressure which reduces perfusion. And this again should be done in the operating theater by a surgeon. These do bleed afterwards, you have to be a bit careful about it. This is a technique we're looking at on the left where you can either use a knife or using electric or tree. And all you need to do is go through the burn tissue until you're far enough down where it comes apart and you can see sort of healthy bleeding vessels underneath. You do not unlike this picture of the right need to slash into unburned fat that's over doing it. This is where you do the escharotomy knees. So it's basically down the outside and on the inside of each of the limbs coming down here. Now, unlike that checkerboard picture you saw before for the chest here, probably two vertical and a single horizontal incision is enough there. The arrows here are to remind you that the nerves at this point for the ulnar nerve here, the common peroneal nerve here are very close to the surface and it's very easy to injure those nerves when performing an escharotomy. So just be aware of them. With these two pictures, it would be quite easy to assess the depth. This is nice and pink that blanches when you press on it, good capillary refill. It's got a wet appearance to it here. The tissue is deeply charred. So we have a deep full thickness burn here, superficial burn here. When we talk about burn depth, there is an importance to it because the deeper burns will almost certainly require surgery. The more superficial burns will heal by themselves. And the big difference between them is the perfusion of the dermis itself. And if you can see an intact clearly refill, that means the dermis is perfusing well, and those burns will often be very wet, whereas the deeper burns will not have a computer refill and will appear dry. And here we can see a good example of that. And this run those two earlier examples is more characteristic where getting a single depth of burn across the entire wound is unusual normally yet variation in depth. But around the sides, we can see very wet, healthy pink with capillary refill. Whereas the air up here as much drier, this is nearly a full thickness burn that's very superficial and that bits somewhere in between. And here we can see an obvious example of a deep burn. But this is also to highlight the fact that around the burn here, you do get an inflammatory response and that doesn't necessarily mean it's affected. That's just a normal response to having a deep burn. Having done that. We do need to put a dressing. We can't just leave these burns exposed. And from a conflict environment focus, we're going to make the assumption that there will be no early burn wound excision. It can be difficult to assess the depth. And as we've already shown that the depth does vary across each burn wound, there needs to be antiseptic properties to reduce the risk of getting infection. And if possible reduce the stimulus for the systemic inflammatory response. And it needs to be easy to use in terms of how many changed dressings you will need to do. This is quite commonly used in Europe. So it's a silver sulfADIAZINE, which is a very standard burns dressing. It's an appointment as you can see there, which has got cerium added to it. So this is antiseptic and the Syria does reduce. The overall inflammatory response is another common product is a silver sheet dressing acticoat is probably the most common brand in Europe. Silver on is another brand as well. And this is basically a sheet dressing which is applied to the burn. It's not as easy as putting a cream on. But again, this is very effective. But if you have none of these standard dressings in modern burn care, simply applying Jell O net to the word and then covering it with gauze that has been soaked in Betadine. If you have nothing else than that adequate, you've done your initial assessment, you've got the fluid resource formula running the patient's doing well from that. And this is where you really have to sit back and then think about what are you going to do next? You've got the dressing on. How long can that dressing stay on for 24 48 hours, maybe longer? Modern burn care in normal situations, very much revolves around making a very early decision about will this burn heal by itself in ideally less than two weeks, in which case, you just carry on with dressings. And if it's not going to heal by itself in two weeks, then early surgery and that's certainly within a day or two is performed. And you may be in that situation now where you have a person who would normally be entered into early surgery. But should you be doing that when it all comes down to what type of facility you're in, what resources you have? Because if you do embark on the surgery to excise the burn that does take time. It is not the most straightforward of procedures. So you do need a skill set there, the patient's will always bleed. So you need blood products available, you will stimulating more pain. So pain management becomes more complex post operatively and it requires more complex nursing care the standard method to excise Bernie's to use what's known as tangentially excision where you shave the top layer of the burn. And then if you make an assessment that there's still burnt tissue, you do another shave and you do that until you're down to healthy tissue. That requires a bit of experience to judge how far to go with it. And here is a deep burn and this was done in a conflict environment. Another approach is to rather than shave, it is just to excise the burn. This burn is deep and actually it burnt right down to muscle. You can see here there is a bit of a Christmas door. So I had to be excised and triceps and just to remind you that's the on the nerve up there, it's very, very close. But if you can imagine having removed the burn like that, you've now got to cover it with a skin graft. You can't just leave it open and this isn't that big a bird. We're talking about a 15% area that's been excised here. That's still a challenge for people who are not used to skin grafting burns to embark upon. So I think you really do have to be very clear in your mind about whether or not it is in the patient's interest and in the whole burn care set up that you have. Are you in a position to embark on excisional surgery? So, what should certainly be done looking after birds. Well, yes, we've talked about the physiological derangement and how you manage that, giving additional fluids. Beyond maintaining an open airway, managing an inhalation injury does require intensive care facilities and can get very complicated. So keep the airway clear if that requires intubation in Soviet. But then you may have to let nature take its course with inhalation injury, you scrub and dress the wound do escharotomy is if necessary. But then before you embark on further burn, get understand what's available in other facilities around you and further away before you embark on a specific burn treatment. If you are in a situation where you have to get on to start exciting the burn. I would advocate not doing it before day three and do a small amount of time, perhaps no more than 10% that makes it more manageable. And if you are in an area where burn care expertise is delivered, but the resources are becoming more and more stretched, well, make sure that the resources have available are focused on those who will benefit most. So try and keep the smaller burns out of the burns units and burn centers and also try not to bring the patient's, you quite clearly are not going to survive. So focus on larger but survivable birds where possible to get the best results, do what you would normally do, so maintain your normal practice. And if that means accepting the fact that you move some of the work elsewhere to not taking every case that comes because rather than try and cope with a lot of work and not do it as well as you normally would if at all possible move excessive workload on. But if you do become overwhelmed, then I would suggest rather than adopting the normal practice of early excision, move towards delayed surgery approach, knowing that the results aren't necessarily as good and accept that in the long term, that's going to be a greater burden requiring long term revision.