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So the topic we're going to cover is going to be a pediatric burn injury. And first thing I'd like to mention is this field manual pediatric blast injury. I think that this is available online and I recommend that everyone involved in any form of pediatric injury should acquaint themselves with this work. Historically, there is a strong overlap between conflict and burn injury and burn injury is something of particular notes where dealing with casualties from war and historical data shows that between five and 10% of casualties seen in deployed military medical facilities will have a burn injury, but the vast majority of those burns be quite small, but there's also a higher chance that you will have another injury as well as the burn. What is hidden amongst that is there are also civilian injuries. So this is not just soldiers be wounded, uh getting burnt in conflict. Some of the civilian injuries are due to wounding from weapons, but the majority are due to alterations in the normal way in which society functions and within that Children are disproportionately affected and some weapons are designed specifically to create fires so incendiary devices. But the largest impact is on the civilians is the alterations to society. So if your kitchen ends up looking like this because of the car conflict, then you end up having to cook with an open fire out in the open. And this is where we see a lot of pediatric burn injuries originated from. And the other thing which is altered in, in society is the healthcare system and you may find that you're not working in the facility that you had been working in previously or its function has changed. And before you embark on treating particularly pediatric burn casualties, you, you have to ask yourself some questions so you can begin to understand what you might be delivering in burned care. And you need to know what is the situation going on? Are you close to where the fighting is? Are you several 100 miles away in a more secure area? What type of facility I am. What is my skill set as a doctor? What equipment do I have here? What other medical facilities are elsewhere? And how might I get my patient's to other locations? So what you're doing is establishing where you fit in the patient pathway. And by finding the answer to those questions, you can understand what could be done at your facility. And from that, you can make an assessment of what should be done in the environment. And you also have to appreciate that in a conflict situation, things can change and nothing is necessarily fixed. And with that understanding your then a position to say, am I here just to provide the initial resuscitation or am I actually providing generalized burned care or even early specialist care? Or maybe I'm actually working in a National Center of Excellence where we provide total burn care. So with that in mind, we can then start to talk about what we will actually do. But we do need to understand a little bit about what a burn does in terms of the injury itself. And there are three parts to it. There is the actual damage to the skin from the bird, the heat directly, this causes inflammation which can have systemic effects and affect the whole body. And also there's the possibility there may be an inhalation injury if we have a look at the skin. So we're talking about the cutaneous burn itself. And the important to understand here is that a superficial burn to be affecting this sort of depth could heal by itself because there are reservoirs of the epithelium deeper down. But a deeper burn may not heal itself as well and may end up requiring surgical intervention. And then there is more generalized effect. Burn tissue stimulates an inflammatory response. And part of the inflammation is that you get a capillary leak. And if the bird is big enough, this can deplete your intravascular volume. And with much larger burns over about 20 to 30% of the body surface area. This inflammation affects the whole body and leads to a systemic inflammatory response syndrome. And then the final components for burn injury is potentially inhalation injury. This in itself has three components. The upper airways can be damaged by the heat, the lower airways where you get the smoke going down into the lungs, that is more of a chemical injury to the lungs. And those bad chemicals can get absorbed into the circulation, uh, and cause poisoning. And the most significant problem in the early management of burns is if you do have heat damage to the upper airways, they will become inflamed, causing swelling and you may get airway obstruction. So we're now come on to the approaches to the management of burns. And the first thing obviously is first aid and the key aim here is to stop the process that is causing the burn by whatever means you have to have and then carrying on cooling the burn as definite benefit if it carries on for about 20 minutes to half an hour. But at the same time, you don't want to make the patient hypothermic. And prior to transfer, if possible, it is helpful to cover the burn as this stops, it hurting as much and also protects it. But an important part is to, particularly when dealing with pediatrics, is to get analgesia delivered as soon as possible. And then once they are at some form of medical facility, whatever it is, it is worth keeping in mind that if you treat burns victims like trauma victims, which which they are taking the normal structured initial assessment as you would for any trauma case, it is appropriate. And I'll go through this. Now, we will make the assumption that there are no other uh significant injuries apart from the burn and this is a significant burn. We don't often take as many photographs of Children with burns as we do with adults. So some of the images I have to show you our of adults start, we're looking at the airway here and we have to ask the question, is there any possibility uh that this individual has a burn to their airway? But he was very well and he was on the phone trying to get someone to come and take him home. But the risk with this patient is that a few hours later, they could end up looking like that where they develop significant facial swelling, obviously wasn't the same patient as the previous slide, but it does show that you can get a lot of swelling, particularly around the mouth. Uh And what we can see here is a tube has already been put down, but uh to open the mouth wider than it is at the moment, uh would have been very, very difficult. So by the time the swelling was this bad, it would be difficult to get an intubation. So we need to anticipate this potentially happening and put a tube down early. However, not every patient with facial swelling, um rather with the facial burn, get this degree of swelling. And if you were to put a tube down, every child, you would very quickly fill up your intensive care unit and they become much more difficult to manage as an intensive care patient. So sometimes before putting the tube down, you need to stop and think about whether or not you think this this swelling will definitely happen. Currently, we have no decision making tools or investigations that can help with that decision. And it essentially comes down to the experience of the clinician and move on to breathing. This patient clearly has a very severe inhalation injury, but we have managed to secure the airway are using a surgical airway. But the problem here, maybe that although the airway is now open, you still cannot get air I/O of the lungs. And this could be due to a circumferential uh chest burns which stop the chest, expanding the chemical damage to the lungs. I mentioned earlier that normally has a delayed of thought, maybe 24 to 48 hours later. Uh So, so the initial problem is the constriction around the chest. And the approach to allow you to ventilate, the child is to perform chest escharotomy knees, uh as illustrated here and we will discuss astronomy's a little bit later in the talk. We want to circulation, the loss of intravascular fluid because of capillary leakage develops over several hours. If a child arrives at your facility very soon after sustaining a burn injury, and they are shocked, then this is more likely to be due to other injuries leading to potentially hemorrhagic shock. So if they are shocked when they first arrived and it is soon after the burn, you treat that shock according to your normal protocols, irrespective of the cause. You don't assume it is due to the burn. They want d disability. And this effectively is talking about neurological disability. And the common causes in all cases are either due to hypoxia, systemic intoxication from absorbed smoke in a child, hypoglycemia must be excluded. They may have other injuries and even in young adults and Children, drugs and alcohol may be a cause of a neurological disability. And the e is for control of the environment with all burns. Hypothermia is a significant risk and it is important to pay particular attention in maintaining a core body temperature, cooling. The bone is important. This reduces the information, but this must be done in a way where you try and keep the patient as a whole warm and our other initial interventions. I'll emphasize it again. For pediatric cases, it is vitally important to give adequate analgesia as soon as possible. Uh And this may require opioids right from the start best to avoid any non steroidal anti inflammatory drugs. For the 1st 48 hours for large burns. As this may alter kidney function and other interventions are laser gastric tube, a urinary catheter in the United Kingdom. It is not normal practice to give prophylactic antibiotics for burns. But in situations where there may be other injuries or there is heavy contamination. For example, if they are involved in uh with the conflict injury, then it can be appropriate to start antibiotics. You need to ensure the patient has immunity to tetanus. But whether that's already they've got active immunity or you give them passive immunity. And then as with all trauma victims, having done these initial interventions, you reassess the patient and perform a full secondary survey, then we come on to more specific burn management and the features we need to pay attention to our is how big is the burn itself from that? We can calculate uh fluid requirements. We start giving them the fluids, but we don't do that just blindly. We monitor and adjust the fluids and we pay attention to the burn wound itself. The most accurate way of doing this is to use a London Browder chart which you can see illustrated here. This is very useful pediatric burns as the areas where there is a letter rather than a number, like there be be half of one side, you see the size of burn, their changes, depending on the age of the patient. So you draw the burn as you can see it on here and use those letters and numbers to help you calculate the size of it for smaller burns. The child's hand with fingers closed and including the palm. It approximates to 1% the total body surface area and having worked out how large the burn is. If it is more than 20% of the total body surface area, then you certainly need to give additional intravenous fluids to prevent the burn shock from forming. If it is less than 10% just encouraging the child to drink more is okay. Exactly where the cut off is it is somewhere between 10 and 20% that there is not sufficient data to give a precise answer to that and to calculate the amount of fluids, I'd suggest using a formula which we will come onto in just a minute. The need for the additional fluid starts at the time of injury. But if the patient arrives to you after several hours, avoid giving them too much fluid to catch up. And the amount of fluid, the formula tells you to use is only a guide and it does not account for blood loss is due to other injuries. And the formula I suggest that is used is that for every percent of the body surface area burnt her kilo of the child's weight. You give to mills of crystalloid 24 hours. People may find that in standard text books and literature, higher amounts going up to either three or four mills is advocated. But I've found that if you are a little bit behind with the fluids and their urine output drops, it is relatively easy to speed up fluid. Whereas if you start off giving them too much fluid and they get excessive edema that becomes much more troublesome to manage. This amount, gives you a volume for the 1st 24 hours and you give half that amount in the first eight hours after the burn and the second half of it in the following 16 hours. And this is based on a crystalloid solution and do not use hypotonic or hyponatremic solutions for Children. And as I mentioned earlier, that amount of fluid is an estimate and it is a guide to how much a patient may need. But what you have to do is adjust the rate of fluid according to whether or not the child is getting enough fluid. And this is best measured while looking at the urine output and your target is between one half and one mil per kilogram our of urine output. And the other test, you can keep an eye on. It is important also to measure the urea and electrolytes constantly. Uh And if you have the capability to do blood gasses, then do them. In particular, looking at the base excess, the normal signs of a tachycardia do not necessarily indicate uh under perfusion because this can be normal following a large burden as necessary. You need to adjust the fluid rate, you both up or down. And if the urine output is below half a mil kilo or greater than two mils per kilo for two consecutive hours, there needs to be an adjustment after the 1st 12 hours. If the amount of crystalloid needed to be continuing to rise rather than give more crystalloid, which will lead to more edema is inappropriate to use. Bullis is of a colloid solution uh of five mils per kilo. And if you have evidence that the child has had too much intravenous fluid and they appear overloaded, uh it is okay to use frusemide as a diuretic but uses cautiously uh in small increment places. Additionally, for Children, they need to be put on to a normal pediatric maintenance fluid regime. And if you use the standard pediatric maintenance regime that you would normally use that, that is perfectly adequate. But if you could start nasogastric feeding as soon as possible, and we are talking within the first couple of hours um that maintains gut function and then some of the intravenous fluids required after 24 hours can be given, uh could be replaced by free water down the nasogastric tube. Well, come on to how you look after the bird wound itself. But the first thing that needs to be done is a thorough clean of the burn. Then you can assess how deep the bird is. You can assess whether there is a need for escharotomy knees, and then you need to cover the wound with something by addressing. So we need to do a clean of the burn. Um This needs to be done under very adequate analgesia, it will be painful. Uh And apart from very small burns, this should ideally be performed under a general anesthetic in a warm operating theater. And we are not talking about a gentle clean of the burn. It does need to be thoroughly scrubbed because unless you do that, you cannot truly make an assessment of depth. And we can see here the child we saw earlier who needed intubating before and after a scrub. And I think you can see there that it is possible to accurately assess the depth burn after authority early having done that you can then assess the need for escharotomy knees. We mentioned before that on the chest, if you cannot get air I/O of the lungs, that is an urgent requirement, but for limbs, it is not not so urgent that it needs to be done in an emergency department, it can wait till you can get them to the operating theater. Uh We can see here on, shown on the picture how there is no dermal perfusion. You can see the limb, it felt very, very tight and the position of the hand clearly shows there is a lot of swelling going on inside escharotomy, knees are best done by an experienced surgeon in an operating theatre, this showing escharotomy which is cutting through the burned tissue. But once you have reached healthy bleeding tissue underneath, you do not need to go further than that, but these can bleed excessively. Uh So it hemostasis is important. And here are the lines of election for where you need to do the escharotomy. He's basically it is on the both the inside, outside of the limbs but paying attention the red arrows here. This one indicates the ulnar nerve. This one, the common Peroneal nerve, they are very close to the skin at those locations. So you must be careful not to damage them. The debt is assessed by just looking at it. The most superficial burns we do not include in the overall burned size. Uh This is where you simply have erythema a little bit like sunburn, superficial partial thickness burns, uh where you see blisters as a very wet appearance and there is an intact capillary refill. Uh These birds are most likely to heal by themselves with dressed deep partial thickness burns, however, are more dry. Uh There is no capillary refill to see there may be redness, but when you press on it, that redness does not go away. That is called fixed staining and full thickness burns have a firm leathery escarre and deep partial thickness. Full thickness burns normally require surgery. It is normally fairly easy to tell the difference between a very superficial bird and a very deep burn, the superficial one has a pinkness to it. But when you press on it, it goes white and then you release it. You see capillary refill and it is wet, a deeper burn has this firm leathery appearance. Uh There is no capillary refill and it is to say, quite easy to tell the difference between these. This will do well do with just addressing, this will do well with surgery. However, most burns are not that clear cut. And here we see a much more typical appearance where around the outside you could see it is very wet and pink, that pink. This has capillary refill up here. It is dry and firm, that redness. There does not go away when you press on it thick staining and this part is somewhere in between the two. So this part around here will heal just with dressings. This will do better than surgery. This could go either way. It's more difficult to decide how to manage the bird wound. Well, come on to what dress of Berg with. This is very difficult because there are hundreds of different dressings available for burns. Uh I don't know what is commonly used in Ukraine. I don't know what is available, but as in general, it is better if the dressing has antiseptic properties, but it doesn't stick to the burn. Uh, superficial burns are very wet for the first few days. So they need, it needs to absorb the moisture and if it will reduce the overall information that is good and that needs to be comfortable, easy for the nurses to use. And ideally one that does not need uh changing every few hours. The most commonly used dressings for slightly deeper burns have a silver component. And this can either be the sheet dressing, uh common trade names for those are acticoat or silver on or you could have silver based creams such as flam a zine. But then you have to also ask yourself, am I in a position where if I have a burn that will potentially benefit from surgery? Should I embark on that as a general rule? If it is anticipated that a burn will heal simply by applying dressings in less than two weeks, then you will get a good result with very little scarring without surgery. And if you think it may take more than two weeks and apart from experience, there is a little to help you make this decision, you have to understand that embarking on burn surgery has a lot of implications for time and resources. They need to obviously spend time in theaters. It is not quick surgery. You may generate a requirement, blood transfusion. Uh There you do need the appropriate skills, nursing care becomes more complicated as this pain management. So embarking on surgery certainly has a cost to it. Uh certainly in the UK and most burn centers we would embark on surgery no matter how big and try and do it all in a single operating session. However, if resources are more limited, it can be done uh in a staged fashion. So you may do just 10% at a time. It should be appreciated that if more than 40% of the total body surface area uh that has been burned to require skin grafting, this becomes a very complex surgical undertaking and should only really be done in centers who are used to doing it. The skill set required to do this is to be able to perform what is known as a tangential excision of the burn tissue and to be able to place a split skin graft on it afterwards. And I mentioned about the phones will heal before after two weeks. If you have quite a large area, sometimes uh an approach is to wait to make any decision for about two weeks. And here is an example where you can see all of this area here was involved in the burn but has healed already before two weeks. Yet, there are smaller areas which are taking more than two weeks to heal. So you could potentially reduce the size of the burn injury. Uh That's an easier burnout to deal with in terms of surgery at about two weeks. And if you're having to provide ongoing care for a child with burns, these are the additional things which it is important to try and uh deliver as part of that care. Uh The nutrition of the child is very important. Uh play therapy, physical therapy, psychological support and that, that will include support for the family and burn wounds as they heal do itch giving anti itch medication uh is important. I hope I've been able to demonstrate how a fairly straightforward uh structured uh approach to the assessment of the burn can be and what the initial uh interventions are. But also revealed that uh embarking on a longer term care of the birds, particularly if surgeries required can be complex. Uh and is best often delivered in places that are used to dealing with uh pediatric birds.