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Uh what, what I'm saying to you now is my, my opinions and not those of UK Ministry of Defense National Health Service or indeed, Baccharis. One of the things that I like to reiterate is what it is that we mean by a burn. There are thermal component that that is the obvious component. We have wet heat, which is the schools or the high pressure steams. There's dry heat, the flash flames, the contacts cold injury, a form of thermal injury, the frostbite, the freezing and non freezing cold injuries. But the thing that I think is particularly important in a conflict environment is the relationship of corrosive substances and nonconventional hazards that form the chemical injuries. And one of the primary triggers for the profound immune and inflammatory response that occurs following a burn injury is the vast amount of damage associated molecular patterns. These are all little fragments of proteins and D N A lipo polysaccharides, lots of damaged and broken substances within the skin. They get absorbed into the local tissues, each and every one of those then sets off a massive cascade and secondary messenger systems throughout the, throughout the body. Throughout that skin certainly, which induces the vascular leak. The hypovolemic shock and the diverse metabolic changes that follow a significant burn within there, there's microbiome dysfunction, the immuno suppression and those recurrent bouts of systemic inflammatory response combined with sepsis and degrees of multiple organ failure that will continue until we get appropriate skin cover. When we think about non thermal and the corrosive substances, the chemical injuries, the same non protein and protein damage occurs to the skin. But without some of the depth of injury Wilk. When a thermal burn occurs, the heat propagates into the tissues and it can set off its own cascades of inflammation with a chemical injury. Those are often contained much more to the skin but can be just as equally destructive. And in a very severe chemical injury, the same depth of injury can be seen. Now, the nature of those chemical injuries is highly dependent on many factors and we'll talk about those in a moment. The other thing about non thermal conflict burns is we have to take them in the context of the individuals concerned. Now, some of these could be civilians. Some of these may be combatants, some maybe industrial workers going about their job and just just in the wrong place wrong time during an attack. The important thing is that each of these individual patient's has a degree of derangement of their pre morbid physiology. They may be dehydrated, malnourished, tired, uh you know, fatigued in whatever other ways we talk about it. They may have been out in the ground again, from a combatants perspective, they may be cold already. Uh their environmental exposure maybe significant. And then we set off all of those inflammatory changes that occur uh resulting in the hypertension, uh end or confusion, a cellular hypoxia. And one of the things that we often forget is the metabolic poisoning that occurs with chemical injuries. The other thing that is really significant about chemical injuries is that often substance is unknown or simply worried about that. People worry that there has been the chemical injury with a schooled burn with a thermal flair with a flame burn. You know what the danger is, you know what the damage was. You know, a lot about that mechanism of injury. But often when we get these unknown substances causing clear changes to the skin, it sets up considerable anxiety, not only for the patient but for the clinical steam as well. The image in that, that I'm showing you here shows a Caucasian male who has been involved in a chemical incident where he's been engulfed in the substance and he's got clear cutaneous changes to his head, to his neck, to his arm and to the to the majority of his back, they mimic thermal burns and often can behave as a thermal burn in terms of that inflammatory derangement. And arguably we treat them, we should treat them in exactly the same way. Again, the other issue with um non thermal conflict burns is they don't occur in isolations. Many are associated with fragmentation injuries, penetrating gunshot injuries. For example, the open fractures, the need, the need for hemorrhage control uh and damage control surgery. So in the A B C D E, the burn uh needs to be put into the context of other life threatening injuries and managed accordingly. And the key thing is not to be distracted by the burn, but focus on those things that are an immediate threat to life. But when we are considering a building that's been devastated in this particular way, there are multiple hazards, not least of which from the immediate effects of the thermal injury, the fire that you can see burning in the top floors, but there's copious amounts of smoke, carbonaceous suit everywhere and unknown hazards in each and every one of those rooms. So when we think about a chemical incident, there are many things to think about, but often there is a longer duration of exposure than there would be for an equivalent thermal burn. A flame burn may be there for a few seconds, maybe it, maybe a minute or two. If someone is particularly unlucky, but potentially the exposure time for a corrosive injury could be minutes, it could be hours and often it may go unrecognized. The chemical injuries often involve oxidation reduction reactions if they are household or simple industrial chemicals, but many of them can also have direct corrosive effects. So that's anything that causes an irreversible skin necrosis. They maybe vesicants, which substances that cause blistering or epidermal isis and could include substances such as sulfur mustard. If weaponized, there could be desiccants which are substances that absorb moisture and water vapor such as silica gel. Now, this doesn't necessarily seem to be an immediate risk for a chemical injury, but if it's absorbed aerosolized, taken into the upper airways, for example, it can have devastating effects to the airways. And then there are a number of other chemicals that act as protoplasm, it poisons. Now, these can essentially form protein Esther complexes or they may bind and inhibit inorganic irons and effectively they stop your your normal metabolism from working that can have local effects or very profound systemic effects. And the risk and degree of chemical injuries varies greatly. It's not appropriate necessarily to do risk assessments in the middle of a conflict situation. But one of the things that we can do is predict local and further distance risks, we can look at those substances present, consider what should an individual or individuals be exposed to those chemicals? What the pharmaco kinetics and the pharmaco dynamics are to generate the adverse effects within the human body and to do this is the right thing to do because it gives you the ability to think about antidotes. Provide the appropriate first aid response is the appropriate training. But if we were to consider the response to each and every chemical that we have documented in the literature that we would be there forever. So sometimes it's about picking the, the environments that are most risky such as industrial complexes and areas that are high manufacturing. Um But sometimes it's even even more simple things. Once we've identified those areas for risk, we can, then we can characterize that they're the hazards. Uh And we can think about the treatments much more. Practically, most chemical incidents are unique. No two incidents are the same. A chemical incident per se is the uncontrolled release of a toxic substance that can result in harm to public health or the environment, industrial site fires or explosions are the most common place, oil spills. Another another one, uh obviously deliberate release or the weaponization of specific chemicals during conflict is not only illegal, but something that we have to consider contamination of food and water either directly or indirectly could also be considered a chemical incident. And particularly if that food or water is then ingested, the chemical injuries that occur can be significant. Similarly, if that water is then used to decontaminate either thermal burns or other burns, first responders, those or you know, paramedics, fire service, fire crews may have made inadvertently use a water source to decontaminate or two to cool, to put out the fire where that water source is in itself a chemical threat. So again, it's not always during a conflict situation uh straightforward. And occasionally, we can see certain disease types that form part of an outbreak when there has been an unrecognized chemical exposure, alluded to earlier on a chemical incident can be sudden with obviously acute symptoms or have a slow onset and a more silent release. Um We have to consider the local effects, local wound, for example, the systemic effects, what what we can see as the immediate effects, but also then the delayed effects. And some of these with some chemical exposures can be the longer term effects with things such as um you know, at certain chemicals that are inhaled, that then give you uh an increased risk of lung cancer and pharyngeal cancer. Again, these are delayed impacts. Um and but something that can impact your health care system uh further down the line, there is always the psychological health and well being of the patient's and uh local population to consider as well. One of my personal concerns is that we never seem to protect the eyes of the chemical of the chemically injured patient. If you consider that 10 mils of a 98% sulfuric acid dissolved in 12 liters of water only decreases the ph from 1 to 5. You can see that uh a bigger exposure in terms of volume of the sulfuric acid requires a vastly greater quantity of water. If that water is delivered effectively to the to the skin surface where it's required. If it can't be delivered effectively. And a lot of that 12 liters runs away or runs over uninvolved areas of the skin. Then considerably more than 12 liters will be required. Uh for that, that volume of sulfuric acid by tilting the head back, closing the eyes and allowing water to run from the eyes away and down the body. Hopefully the vast majority of um splatters to the face and uh and or enter the to the to the head area will run away from the eyes. We can fix the skin by skin grafts if needed or by letting nature uh heal wounds slowly over time, but we almost uh cannot fix the chemically damaged. I so I think one of the things that must be uh uh advised to prehospital care and to all the first responders and emergency departments and to anyone managing these injuries is just take care of the eyes at every opportunity we need to remove all the clothing. Um But also consider that some of that clothing could have a forensic implication. Should you think about chemical incidents having some form of um uh international law, uh consideration and again, copious LaBarge with water is the easiest and simplest way to decontaminate uh and to dilute any, any injurious agent. Now, we've, we've mentioned some international law again, I'm not going to go through the entirety of protocol free. Um All, all that I will say is that there are legitimate uses of things like white phosphorus in a, in a military context against military targets. But there are some very specific um uh reasons as to why something like munitions as seen in this picture dropped into a concentration of civilians would be seen as a breach of international law. However, forensic evidence is something that can be, can be collected either photographically or practically uh for, for a lot of these, a lot of these injuries, white phosphorous itself has an unpleasant garlic like odor. Uh It has a phosphorescence ability and also a commie luminescence. So it tends to glow green and reacts with air to to have a green glow. It is pira for ICC meaning it spontaneously ignites in air once it reaches a temperature about 44 degrees Celsius. And what it as it burns, it releases a toxic white smoke which is toxic by inhalation. Uh the uh substance itself, white phosphorus is toxic by ingestion. Uh and the substance in its own right, is corrosive and irritant, the skin and obviously causes a thermal burn. Should it ignite above the 44 degrees Celsius mentioned earlier. It is also hazardous to the environment. Now, in treating white phosphorous burns, there is limited evidence in the open literature for best practice. Um The most important thing is to uh have your own personal safety and protection at heart. And um I remember that the white presence of white phosphorus in wounds can spontaneously ignite. Should it should it react with the air or reach a temperature above 44 degrees Celsius, white phosphorous itself is poorly soluble. Um And therefore, copious irrigation is very good at uh physically agitating and removing it from a wound. But again, make sure you collect uh the effluent or at least know where that influences going because you don't want to have little bits of white phosphorus igniting within your theater at a later date. when things dry out wet saline soaks are very good at preventing the air getting to the the phosphorus and preventing re ignition. Um And that's very good for transfer from either the scene of injury or within the hospital environment. Identification with an ultraviolet light is useful and that relies on that kidney luminescence and phosphorescence properties of white phosphorus. Um And often the the small lamp, the woods lamp that's used by the ophthalmologist to look into the eye that the blue light is adequate enough to, to trigger a luminescence. Personally, I would never use copper sulfate, particularly if there's multiple areas because the absorption of copper sulfate is toxic and it's very difficult to monitor how much of the copper sulfate is being absorbed by, by the an individual patient. Um I think there are better ways of identifying it. I think if you're concerned that you haven't identified all the phosphorus in a wound or you don't have an old fire light and you, you don't have time or indeed resources on your side. Arguably a radical surgical excision of that wound eliminates any residual white phosphorus uh and remove the problem once and for all, unfortunately, it does mean you have created a larger wound for yourself. Um But when, when options are limited, that may be an appropriate consideration. And I think one of the other things we need to think about is delayed grafting, mainly because the chemical damage to the wound bed. Even if the wound bed looks healthy is often um it often takes up to 77 days for that wound bed to stabilize itself, ready to be grafted and to accept an autographed. And I think one of the things that I, I I reiterate whenever I give this, this type of talk is don't forget the inhalation injury. Um the white smoke that we see uh emitted from white phosphorus uh is a highly toxic. Uh it contains uh it reacts with open air, it can, can conform phosphene. Um It will, it will also for phosphorus pentoxil. I'd a phosphorous try oxide and uh different types of phosphoric acids, those in their own rights. If they, if they mix with additional water vapor, um can penetrate very deeply into the, into the lungs and cause a very significant toxic injury to the lungs and pulmonary edema. It can be seen as a as a fairly late stage after exposure to white phosphorus fumes. So a very careful history is required because if they've been within that environment, uh maybe, maybe not directly on fire or with white phosphorus on their own clothing. But in an area where white phosphorus may have been burning chronic exposure to or a significant inhalation of that smoke can be, can be a very significant delayed injury. Chlorine is something that we very rarely see, um, uh as a, as a burn threat, certainly within the UK and, and, and most of Europe. Um but do remember that lots of water treatment works have large uh containers of liquid chlorine that is that is used to chlorinate the water for it to be used as drinking water. In the event that the water treatment facilities are targeted, the liquid chlorine itself can result in a cold injury. Um if not directed a frostbite, then certainly a a a pure cold injury. If the if excess chlorine gets into the drinking water or into other water sources, then it becomes a very significant issue. As I said earlier, if that water is used either as a drinking water and consumed or used as a decontaminate. Uh, the inhalation of the chlorine gas can be significant causes a number of, of respiratory symptoms. Um And the the onset of pommery edema is often delayed if it's just exposed, just a chlorine gas exposed to the skin, there's often a very severe burning pain, uh very early onset erythema, uh and then blisters that evolve over the whole the whole of the exposed skin. But the concentration of chlorine does need to be reasonably high. Remembering that crawling itself is heavier than air. And so it tends to sync. But for people who may have been exposed, particularly workers, for example, in a water treatment facility, if they are hiding or they have crawled under tables or other items to protect themselves, they may inadvertently be crawling down into a higher concentration of the gas. Nitric acid. Again, is another industrial and occupational risk. Um, has multiple uses. A lot, a lot of chlorine, a lot of uh nitric acid and such lights are used in the manufacturing fertilizers and uh in the, in the uh processing of um uh crops, for example. Now, nitric acid itself is a contact irritant but rapidly dissociated into its respective irons. Um The, it's therefore toxic at the exposure site, whether that be your lungs or the skin. But thankfully, systemic effects are very rare. It can cause severe cutaneous burns and blisters. Um And again, like like many of these inhaled toxic products, um, the onset upon uh edema often has a latent period of up to 30 hours ingestion of um open, uh a liquid component of nitric acid. It can be fatal. And again, I just reiterate the, the uh my main, my moment issue which is the chemical injury to the eye is that um, often a lot of the chemical injuries that we see our uh splashes that are projected away from, from a uh an exploding source, for example, or, or, or some something that's been been damaged by fragmentation injury. Uh and it causes a pebble dashing to the, to the face with multiple small lesions, most of which just need a good scrub and uh and to be left alone uh to heal by themselves. Um but in irrigating uh the uh the face on the, on the right hand side of the screen, you can see that there was a slightly um slightly more exposure to the, to the, to the left eye. Uh and uh in, in so irrigating, um uh they seen a lot of the contaminant was washed into the eyes, resulted in blindness in that, in that, in that individual left eye, despite the fact they were stood together and exposed to exactly the same uh quantities and type of corrosive substance. Uh One ended up losing uh sight in one eye and significant volume in the other eye mainly through the way it was decontaminated at a time. I just wanted to give a quick mention of procedural pain management. Um It's one thing to manage burns, whether they be chemical or otherwise. Uh But a lot of these things do, do hurt and in order to get uh appropriate treatments, most of them require time in theater. Now, there are obviously the pain ladders that we can use. Uh And I think one of the things that we have learned to use with great effectiveness in the United Kingdom. And a number of our burn centers is things like oral ketamine, midazolam, internasal diamorphine, intranasal fentaNYL. And then something that we referred to as Key to Fall, which is intravenous ketamine with propofol, which is usually administered by an anaesthetist. But can be, it effectively gives a very, very deep conscious sedation. Whereby a number of procedures including full changes of burns, dressings can be, can be done without the need uh to be in a theater environment, providing the environment that you have uh enables you to give clean management of those wounds. If the theater is the only place that you have that can deliver clean treatments, then then these techniques are not necessarily as useful. What it does do is enable multiple uh interventions to be done. Uh act, not necessarily rather requiring an operating theater to be to be uh used. And again, I think there's a number, a number of things that, you know, one protocol does not work for every patient. Uh often we're trying to manage the anxiety, particularly with things like those chemical, chemical injuries. And again, I think one of my final comments um is, you know, you're there as part of a team, whether it's a dedicated burn care team or as a, as a an emergency team. And each and every one of you will have different ways of managing to the injuries that you see and to the uh to the, to the implications for you, for your families and for other patient's, you'll be treating later that day and for the remainder of the conflict, um your batteries will not always be fully charged and uh they look after each other uh and that will enable you to look after your patient's uh as well as you can in the circumstances you have. Um yeah, burns are complex. The combined burns trauma is always a challenge, but I hope that's been useful for you.