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this. I think I think we're We're still quite a small group, aren't we? So if anyone, um, has any questions, feel free to either shout out or or put them in. I'm not sure I'll be able to see the chat box, um, on from this mode. So, um, yeah, Anyone got any questions? Either shout out or leave them to the end. It's up to you. So, um, um, I'm a burns and plastic surgeon, so this is your opportunity to ask any questions you want about burns, And no question is too simple. Um, and this is going to be about the immediate and early management. So the, you know, the first, um, first few days after a burn injury. What we what we do? Well, obviously, the very first thing to do. Uh um, you know, usually by the time they get to see a doctor, this has already happened. But just, uh, if they are still on on fire or the clothes are smoldering, obviously you got to put the fire out. Um, as I say, that's usually happen by the time I certainly get to see them and then the next important stages to cool. Um, the burn, Um, and we're going to talk about why that is, um So, first of all, have a think about what happens when you heat damage the tissues. What actually happens? Um, well, your cells, they can take a bit of damage, a bit of heat damage. And what will happen is that the proteins will denature. And by denaturant what I mean is that the proteins change shape and as you know, proteins, they rely on their shape for their function. So if if you, for example, an enzyme, if it changes its shape, it's no longer going to work. Um, and so a bit of heat, the cells are going to the proteins and DNA are starting to get damaged, but they've got a repair mechanisms, so they they will be. They're busy trying to repair the damage. Um, hoping that the heating is this the the flame injury or whatever the heat is and you can get on. And you've all had I'm sure you've all had, um, mild, superficial bands Where, um, you're, um if you managed to heal, um, And if left no scarring at all. No, no trace. You wouldn't even know it's that you've had a burn there, so that's been a reversible injury. However, there's only a certain amount that the that the cells can take. And, um, if you if the damage is such that it overcomes the cell's ability to repair, uh, this issue, then that becomes, um, irreversible. And here is a cross section two. Uh, imagine this is a cross section through the skin and on the left hand side you have normal skin, and you can see the hair follicle there. And hair follicles and other adnexa structures such as sweat glands, are very important because, um, the they are lined. Uh, can you see this blue line here? This is the This is where the epidermal cells start life, and then normally what they do, is they. So the these are these are adult stem cells and they will, um, divide and and and they differentiate. And then your skin comes off the top and flakes off the top, uh, for example, like dandruff and you can see these stems. These cells line the hair follicles, which is very good, as you're going to see, because that's how our burns heal on the right hand side of the side. You've got a superficial burn. And what you've got here is you've got the dead tissue on top, which is colored in blue there. And then you have, um, uh, fluid. And that fluid is being leaked out of, uh, by the Germans here and that. So that is what you call a blister, and you've all had a blister. And you know that sometimes the the dead skin on top actually detaches. And that's when your blister pops or your d roof. Your blister. Um, luckily, these stem cells here, these hair follicles here, um uh are not burned. So that is how this is how this burn is going to heal, because in the normal state for the stem cell, so you're going to go into the normal side of the UN burns the skin, the stem cells if you imagine them living. Um, if you imagine them looking down from the top, they are all surrounded 360 degrees. They're surrounded by fellow epidermal cells and the cells. They sense that they know they can. They can feel they can sense that there completely surrounded by epidermal cells and If that is the case, they say Okay, What I'm gonna do is I'm going to just multiply and I'm gonna migrate up to the top and then I'm going to flick off. However, look at the Imagine this. The cell that's on the edge here. This this cell does not have any any epidermal friends to one side of it. Likewise, this one doesn't have any epidermal cells to one side of it. And they sense that there is a gap and the cells on the edge here. When they sense that there is a hole that needs to be filled, they change their phenotype and they say, Okay, now I'm going to change. I'm going to I'm going to multiply and I'm going to migrate across. So these cells migrate across here and these cells might a great across here until they meet each other. When they meet each other, they're back to the situation where they're completely surrounded by, um, epidermal cells. And they change phenotype back to their relatively, um, dormant phase, and they just behave as normal epidermal cells. So that is how your superficial burns heal from the hair follicles. And that is why um, if you Now that you know that that that is why you can explain why, um for example, men, hairy men. He heal quicker than, um women because in men are generally hairier and that what that means is the hair follicles are bigger and deeper. And that also explains why in Children who also are not so hairy and their hair follicles are are not as deep, um, they heal worse than adults. So let's, um, look at this is a typical burn. This is a very common burn that the commonest burn that we see in the UK is of a pull down from a cup of tea. So the this is it's typically a toddler because the toddler is old enough and big enough to be able to reach up for that cup. And it sees its mom with the cup, and he thinks, Oh, that cup must be very interesting because she keeps going back to it every now and again. She keeps going back to that cup. Wonder what it is. I wonder what it is and they reach up and they pull the cup of hot tea down onto themselves. Um, and I don't I don't know about in Ukraine, but you're probably more likely to drink coffee there. Um, but you can see that it's, um it's a superficial burn. And here the blister has actually come off the skin. The top layer has come off, and now what you're looking at is you're looking at the dermis, the top side of the dermis. Now, one thing that was missing from that picture, um, of the cross section through the skin was, uh, the nerve endings. Now, the nerve endings are present in the dermis, and they're normally protected because they've got the epidemics on top. But here, the nerve endings are going to be unprotected, and they're going to be exposed to the air. And I'm sure you've all had a superficial band. And you've all realize that even the movement of air over your superficial burn is sore. And that's because the nerve endings do not like being exposed to the air. They like to be covered up. Um, And now that you know that you'll realize, well, that's why we often will put address it. One of the reasons we will put a dressing on the burn is because it makes It makes a superficial bone much more comfortable if you can include it. And therefore, um, the nerve endings aren't, um, exposed to the air so you can see that this is very painful. What are the paradoxes of burns is that the more superficial burns are the most painful and the deeper ones, which are more serious. The deeper burn is obviously more serious, but paradoxically, because the nerve endings get cooked, you can, um, end up, um, in a situation where the the the deeper burns are actually pain less. So let's have a look. Now, here we go. Here, we've got a This is what we would call a mid dermal burn. So the burn is through about halfway through the Dermish. But luckily, our good or our friends, the epidermal stem cells and that basil layer are still present are still intact. So this the gap is a bit is bigger, So this burn is going to take longer to heal. Probably take two weeks to heal rather than the one week, but it's still going to be, um, possible for this burn to heal on its own without the need for any surgery. And here this is a So this is the appearance of the deeper a bit deeper you're looking now. Can you see that there are little pink blotches within the dermis? What you're actually looking there at There is coagulated blood vessels, groups of blood vessels that the that the the red blood cells are trapped in them and they can't move. So a superficial burn the first one that we saw if you touched it with your gloved hand or if you took a a swab and touched it it not only would it be sore, but it would you would notice that the skin blanches so you would. That what that means is you able to move the blood cells so you press down and the blood cells would move out the way. And then when you release your finger, the blood cells would rush back in this situation in the mid herbal burn, that's going to be a bit sluggish. And as you get deeper, that refill doesn't happen. But the mid term ill it would be a sluggish return of, uh um off blood, what you're gonna see, and then here we have a full thickness spurn. You see, on the right hand side, all the layers of the skin, the epidermis and the dermis have been cooked, and that includes all those epidermal stem cells. All those basal epidermal cells are now gone, so this cannot heal on its own. This poor cell here has to. He's going to try and grow all the way along here until it meets. It's it's friend. Depends on how wide this is. So anything this, I mean, obviously, this is only tiny. There's the size of a small coin. Then it will heal, but it'll heal with a scar. But if it's bigger than that, it just it will. It needs surgery. That's how that's why we do surgery for these full things burns because they don't have the capacity to heal. And this, when you look at the full thickness, spurn, it looks like leather. It's cooked hard, and it's insensate because they're, um, the nerve endings are all cooked, and if you feel it, it feels hard and it feels tense. So when we cool the band, what we're trying to do is we're trying to get the the temperature of the cells back to within a physiological range. And obviously the best way to do that is with cold water. Don't use things like ice, because if you if you use ice, remember those cells that have just had that heat injury from being too hot will now be too cold. And, um, you can actually cause more damage by using ice. And, uh, there's a lot of old wives tales about what you can put on bands. Um, you know, don't put toothpaste or butter or anything like that on, UM, it's not going to help. Also, companies that make these that make these dressings will try and get you to use these gel dressings. Um, and you'll you'll. You'll often see them if you if you go to some of any of the conferences that manufacturers trying to sell you these dressings, Um, and they they smell very nice, Um, but the problem is that they're not as effective as cold water, and if you put it on a burn that is still hot, then it can actually keep the heat and act as a heat sink. And actually it can actually keep the heat in rather than cooling down. So these are fine to put on once you've done you for cooling with cold water, remembering that you've got to cool the burn but warm the patient. So, for example, if it's just their leg that is burned, then cool the leg. But remember to keep the rest of the patient warm, particularly in the winter months, they can get very, very cold. Um, I remember, uh, seeing a child once, and they had it was in the winter and they would put they put cold wet towels on to cool the child. And the child was severely hypothermic because, um, we got very cold very quickly. So cool the burn, but warm the patient The optimum time to cool the barn is 20 minutes. Um, and that we know this from, um, experiments have been done in pigs. Um, more than 20 minutes doesn't do anymore. Good. But if you've not had the full 20 minutes, do 20 minutes of cooling. Um, and you know, so if you if you are one of your kids, get to burn in the future cold water for 20 minutes so that the best way to do that is with under a tap or in in a cold shower. And so, yeah, don't confuse cooling with the dressing. You do the cooling, then you do the dressing. Um, and so this is just a chart to show you the temperature, Um, of a of a burn as it gets cooled and that narrow a problem for ourselves as they can only exist in this very narrow physiological range. And you see the cooling It actually takes quite a bit of time before the cells will get back into that physiological, um, range. But that's what you're trying to do. Um, and yes. So this this work has been done. Um, uh, in pig models, and it clearly showed that water is better than anything else. Um, how cold does the water need to be? Anything between two and 15 C. Uh, will cool down. Um um, the burn now, chemical burns are different, obviously, because they you're not cooling. You don't have to Cool. Um, these burns, but they there is a There are antidotes that can be given for, um, chemical burns. So, um, for the first way to treat chemical burn is whether with dilution with water, water is always going to be available, but there are certain chemicals that have certain antidotes, and it gets a bit complicated. But luckily, there is one, um, universal antidote, um, called Differin, which, um, we'll work on any all chemical burns. So, um, in the old days, you used to have to remember lots of different antidotes for, you know, acids, alkalize, etcetera, etcetera. Uh, luckily, there's one antidote. Die for tree in which you can, which will treat all chemical burns, so that makes it a lot simpler. Water is the cheapest, um, way of treating a chemical burn. Um, but you got to be fast with water to get it on. It wants the chemical. And by this I mean an acid or an alkali or a phenol, etcetera. Once it is bound to the tissue, the water won't remove it. So you got to get it on within. Take 10 seconds of injury. Um, which is quite a strong ask. Um, whereas if you use an antidote such as differ terrin, they have such a they have a higher affinity for the chemical agent than the skin does. And therefore, even if the chemical agent is bound to the skin, they the the agent can, um it attracts the chemical so much that it actually pulls the chemical out of the skin and, um, onto itself. Okay, so we stopped the burning. We've called cooler burn, But now that the next important thing is to not forget about the rest of the patient Now, you saw the you know that picture I showed you off the full thing, the poor girl with the full thickness burn. Now it's the very dramatic injury and people the problem with big burns is it's so, um scary for you as the treating doctor that people can forget that they might have another injury. And, um, when you say, if you are in a house fire, if your house is on fire, you will do anything to get out of that fire. So if you're on a first floor, second floor, or even higher, um, up in the building, you will jump out of that building. If that, um because you what the pain will get so severe that you'll do anything to get out of that when you jump out the window. And when you do that, you can break your legs or you can break your neck or you break anything. And the problem is that the burn is a distracting injury. And people, uh, forget to do the normal a t l s a B c D. Etcetera. Now we like to assess the size of a burn and the reason that we like to do that. There's many reasons, but one of the reasons is that the the amount of fluid that resuscitation that we give our burns patient's, um, is is based on the size of the burn, and you can predict how much they fluid they leak. Um is fairly predictable based on the size of the of the burn. So you can knowing that you can give them fluid, um, at that rate to, um to prevent them becoming hyperkalemic. Um, it also is important in, um um, as as it is, it gives you prognosis of the survivability of the burn we used to in the olden days, you used to add the patient's age with the size of the burn as a percentage, and then that used to give me their sort of the chances of them dying. Um, so So, for example, if you're a 20 year old and you had a 70% burn, then you had a 90% chance of dying. Were a bit better than that now, but not much. Still as a, you know, as a rough guy, that that is still, um, fairly accurate. So how do we How do we assess the size of the men? Well, there's a number of ways, Um what this the the simplest way. And this is something that the paramedics do so that these is just just to use cereal having. So what you say is, you say, um, is it over a half of the patient or under a half? Or is it between a quarter and a half, etcetera? And they use this technique because it's although it's not very accurate. Helps them, um, decide where the patient needs to go. Which kind of which kind of burns facility does it need to go to a special burn center? Or can it can it be treated, um, in a in A in a more normal, routine hospital? Um, the next way is to use, uh, with what we routinely you to use is what's called a London Browder chart and This is where the body is cut up into, um um, various sections, Um, like, four on the back of the forearm, etcetera each. Each part of the body will be allocated a percentage and your color in the chart. And, um, you add up the percent and another. Another way is to say, Oh, that should that should say 1%. The hand is 1%. Don't know why it's just 15 that so the palm of the patient's hands, the patient's and remember not, um, not your hand patient's hand is roughly 1% um, and but And another common way is called the rule of nines. So if you, um, a leg is going to be two nines, an arm is going to be 9%. The trunk is going to be two nines on the front and two nines at the back, and the whole head is 9% and you can work out. Um, what the size of the burn is there. Um, then, um, remember, burns are going to be unless they're all full thickness burns are going to be very painful. So analgesia and what we would usually uses IV morphine. So you would give them, um, a dose to try trait it against there against their pain. So give them something like, um, point, um, 0.1, um milligrams of morphine per kilo. So 70 80 kg kilo, man. Give them eight. Uh, the grams of morphine. And see, um, if that, um, it stops the pain, and if it doesn't stop the pain, give them a bit more, and you give them a bit more IV, uh, you titrate it to effect. Everyone gets oxygen, and he burn it just like any other trauma injury. Um, oxygen is always a good idea and then put a dressing on the wound. Now it's what you put what the dressing you put on will depend on where the burn is going. So if if it's just you, that's if it's you that's going to be managing this band, then you can dress them with whatever you want. But if you normally what happens is they will. They will be referring this burn onwards to the burns unit. Um, and what? Just because the germs, you know are then gonna have to take the dressings off. What we normally ask in this country is too, that they just put Cling film on on the wound because it's only going to be in the UK a small country. Um, it's only ever gonna be a maximum of a few hours before they get to A to a burns unit. Now, I appreciate that Ukraine is a lot bigger country. So, um, you would What I would do is I If you're not going to be looking after the burn yourself, I would ask the Burns unit what they would like to put on the burn. Um, and just do whatever. Uh, they tell you we like cling film because it's clear and it's cheap. Um, and it's easy to remove. It doesn't stick, whereas other dressings can stick, and it's painful for the patient. But just remember, the reason I've said in strips, not circumferential E is because you can end up with a situation where if you, if you're the burn, will swell after, um, the injury burn starts to swell. And if you put the clean film on tightly, it might, um, cause cause a problem. If you, uh, with that swollen lym and it might, um uh, uh, restrict cause a restriction of the blood flow. So that's clean film going on a on a band there. You can see that, and it's easy for us to Not only can I see through it, but also it's easy to remove. And then you're gonna get a history from the mechanism of the burn and in particular with if there's a history of there being a burn in an enclosed space so that in a in A in a room and the reason we want to know that is because if they're if that if there's been a house fire and someone has been in a in an enclosed room, they are at risk of breathing in all the horrible toxic stuff that's in smoke and they can get an inhalational injury. Um, like so also, if you're in a in a tank, for example, uh, enclosed space there going to be forced to breathe in, um horrible Um um components of incomplete combustion. Where Sorry, Professor Jeffrey, Just a question asking what is playing film. So I'm sorry. I don't know. Uh, does anyone anyone you know, it's I think I think, in the States they call it Glad wrap. Do they It's the stuff that you would wrap your sandwiches in. Or, um, you know, it's the stuff comes in a roll. Most kitchens have got it. Um, yeah. I'm sorry. I don't know. I assumed everyone in the world did cling film. But maybe that maybe maybe it's just a British thing. Um, okay. Where? Right. So, yeah. So if you've got your burn is outside you, it's unlikely to have a very unlikely to have an inhalation energy because the smoke will be, um, will be so concentrated in your lungs. So these are the kind of you want to know how long they were exposed to this to the heat? How? If you can get a, um, idea of the how hot was the the agent? If it was a chemical, what kind of chemical was it? And you know what was the strength of it? And then you get some strange things, like So, for example, this is a roofer, so he's got he's been up a ladder pain putting bitumen on a roof, and then the pot of bitumen is the hot, um, bucket has fallen on his head. Um, so this this is, uh, someone has fallen into a into a fire, Um, in a in a bonfire. Um, it's kind of injury. Very common at this time of year in the UK when you examine them. So as as well as asking them about where they were, they're trapped in an enclosed space. You're looking for other things that you're looking for to see if they've got risk of airway injury is Have they got suit up their nose? Have they got suit in their mouth? Have they got singed facial hair like hair, scalp hair, uh, eyebrows, eyelashes. Are they singed? And then when you you speak to the patient you wanted to see have they got a horse voice? Now, obviously, you won't have probably spoken to this patient before. You won't know what their normal voice is like, but the patient will usually be able to tell you, um, if their voice has changed, because if if if they have a, um, an upper airway problem. The problem is that they the the swelling and the your neck can become very swollen, and it will become very difficult to intubate. Um, these patient's So if you suspect an airway injury, get get an anesthetist down, someone who's very experienced with dealing with airways and get them to intubate the patient use. He sits on the tongue there and that all will go all the way down into his lungs. Let's sit on the hard palate. And then when you do lavage, when you when you do suction, can you see the horrible black stuff that's going to be coming out? Uh, it is This is a chemical burn. Uh, it's, um it's actually petrol or gasoline. So, um, Jasa lean obviously will cause a thermal burn if you ignite it. But even if it's not ignited, if you soak, if you're soaked in it for a long period of time, it will cause a chemical burn like this. So the story with this man is he was a mechanic and he was working. Um, he was, um, replacing the petrol tank of a car. So he was under that, you know, he was in the pit and he was wearing his overalls and he was soaked in petrol all day, and it causes cause disappearance here. And the problem with with petrol is that it can be absorbed into the bloodstream. and it can cause, um, a problem will, it will go into the fatty tissues, Um, so it can cause lots of problems with the kidneys And, um, and the liver and also pneumonitis this appearance here, this is a This gray appearance is appearance that you get with Hydrofluoric acid. Hydrofluoric acid is commonly used in industries as a metal cleaner. It's very good at cleaning metal used in the food industry to clean out. You know, the vats that have been cooking the food. Um, and it's also used. You can buy it in, Uh, you can buy in, um, in the car. A store? Uh, it's good good at cleaning your alloy wheels. Um, and it was very, very painful. And the one of the problems with Hydrofluoric acid is that it can cause hypocalcemia. And that is because the the fluoride in the hydrogen fluoride fluoride binds to calcium, um, to the patient's calcium. So they can Actually, the fluoride likes calcium more than it does like hydrogen, and it can cause a significant hypercalcemia. There's enough to kill you. Um, I think the smallest burn that's resulted in the death from a Hydrofluoric acid burn it has been 2% of their total body surface area. So someone comes in with a Hydrofluoric acid burn, take it seriously and measure their, um, calcium levels into E. C. G. S and and admit them. Um, so this is a tip. This is a a burn here in a in a child. And can you see the slough that appears? And the big risk, the biggest killer in a burn injury is infection because the slough is this dead skin that's on the top of the, um, burn is a is a great medium for bacteria to, um, to grow in. Uh, so what we've done, what I've done here is I've taken this, taken this child to theater and given it a scrub to get rid of that, um, that sluff. And then we're going to put on the dressing a nice occlusive dressing, which is gonna, um, And the occlusive dressing is going to be very painful for the child. Very, very comfortable for the child, because those nerve endings are gonna be occluded. And so this you can see that this is, uh, two weeks later, or the the dressing the burn is healing And it's, um uh, Midst Mhm. The bone is healing underneath, and the dressing is being lifted off as it as it heals. Now burn excision. So what we do when we have a full thickness burn? Um, we have to get rid of that dead tissue. And this is the stuff that we're trying to remove. We're trying to remove the dead tissue. Um, uh uh, And there's also get rid of the any bacteria that are there. And this is a life saving thing, because if you don't chop off the dead tissue, they put the patient's will die of infection, that's otherwise name for this is debridement. Um, sometimes we have to be radical with our debridement, and we were too an amputation. But most of the time we want to do a tissue preserving, uh, surgery. So what we're trying to do is, um, remove the dead tissue, but leave as much healthy tissue as you can, and we use various. We've got various ways of doing this. Various knives, etcetera. Um, I wish I'm going to show you, um uh, in a minute. So So, um, a burn like this is an electrical burn. Um Obviously, this has to be amputated. You know, there's no way of saving that. So that would be fairly, um, easy decision to make. Sometimes we do a full thickness excision like this using it, uh, using a diathermy machine. Um, because the reason for doing it like this is quite mutilating, but it's quite bloodless. Um, so if you if you're worried about losing blood, this is a good way of of, um, preventing that, um, that's called a fascial excision. And because if you what you're doing here is with the you're going straight to the root of the of the tree, the blood vessel diathermy ing it there. Uh, rather than having to diathermy all these little branches at the top, it is and is, and you get great skin graft take. However, it is, um, quite mutilating. Um, as, uh, I think I've got a picture like that. You can see it's not It's not a great cosmetic result, because you've taken out all the fat you got down to the fascia. Um, Now, this is just to show you a series of, uh, photos of what we do for surgery. So you clearly, hopefully you can all see that That is a full thickness burn there. If you If you knocked on that with your finger, it would It would sound like wood. Um, this is so this boy, this is a say nine year old boy, very reluctant to tell you what this mechanism of injury is. What do you think? Does anyone have an idea of how? What? The mechanism? How he he got this band to his thigh, Very reluctant to tell you because he playing with matches And, uh, you didn't. Didn't want to get into trouble, so yeah, and the boxing matches ignited. So I'm going to chop it out because I need to chop out the dead tissue. Um, and you can see if you look at the pictures. The whole is a lot bigger, isn't it? Why do you think that is? Have I been really radical in my surgery and taken out way too much tissue? No. The different The reason is it's got bigger is because of the skin in a young person is very elastic. And it's like cutting an elastic band and it pings open, so you can see if, um, the hole is bigger than you think. So don't take your skin graft before you before you've exercised. Done your excision. Now you see, we're down to healthy fats. That is nice. And healthy tissue. Uh, another way of doing a, uh, an excision is by using. It was called tangential excision. So at a tangent, and more like this, really, because it's a three d tangent. Um, and this is to try and preserve as much of the viable tissue as possible. However, it does cause a lot of bleeding. Um, and you But you want the tissue that's left to be healthy enough to be able to take a skin graft. So you you want to take out the zone of the dead tissue and the and the the tissue around it. So can you see that I've done a shave? We've done a shave, and we're down to a healthy tissue and healthy tissue. The dermis is white, and there's no thrombose veins, and the fat is yellow, and we have lots of different knives that you can use for this. This is the commonest kind of knife you use or what's the knife? Uh, this is a silver knife that you would use for doing the fingers, for example. And this is a A another type of knife that use it. This is a week. This is how it was first described. It was actually, um, described from in Yugoslavia this technique in the seventies. So you can see and this is the the hashed area is the dead tissue. So with our first pass, you can see we take most of it. But there's two areas that are left. You can see there's some healthy tissue being sacrificed, though, and then with the subsequent passes we take until we get all the tissue. So, for example, this is a a burn here to the Penis. Um, and then I'm taking my blade and exercising the burn a bit like getting having Adana kebab until it's you get down to the healthy tissue and then you can put your skin graft on it. Um, so it, um, allows. There's another, um, technique called the versus, yet which allows you to take a narrower strip of healthy tissue. That means that you can that you're you're leaving behind more tissue, so it takes a thinner cut every time it takes a cut. So for in areas when you're doing an excision of the face, for example, where Kozmus This is very important. Um, you would you would use something like the versus yet. So this is, uh this is, uh, an iron burn and a on A on a toddler. Hot iron has fallen on the burn, and then we're going to use the versus jet here, too. That's the versus. Yet using the versus yet to, um, um, exercise the ban. And then we put on a skin graft like that. That's what it looks like at day five. You see, it's a mesh skin graft. And then at nine months, there's, um you know, it's hardly there at all. This is how we take a skin graft. Um, we you we use a dermatome to take a a sheet of skin, and that's what the the donor site looks like. Once you've harvested the skin graft, you've taken off a very thin layer of skin and you're leaving this behind. How is this gonna heal? You all know how this is going to heal. It's going to heal from the hair follicles and sweat glands. Isn't it just like your burn does and you end up with a thin bit of skin, which we will often mesh. You can see it's so thin that you can actually read the the instructions on the on the meshing machine through it. We often mesh because, um, if putting it through a measure like this for two reasons, first of all, it increases the amount of skin available. But also secondly, for an irregular, uh, wound, it contours better. Now, this is the donor site. I'm going to put an adrenaline soaked gauze on there. Just soak to stop the bleeding. Then we're going to put any kind of dressing on. And then this is the thigh, the boys thigh. Um, so we'll change the dressing at about five days. This is what it looked like, and this is what it looks like at about three weeks, so it's completely healed. Um, sometimes, however, we use artificial skin. So this is this this girl, she, um she was sledging. It was a winter and she was sledging, and she she went down the field and couldn't stop at the bottom of the field and ended up going onto on onto the road and went under a car, and her face was stuck up against the exhaust of the car. So this is an artificial skin that's gone on called Integra, and I've done this because it's a young girl's face and it gives you the best cosmetic results. So that's what it looks like when it's on. That's when it looks like one. Once, um, once it's healed, it's always starts out to read. But then it settles down, the color settles down and you end up with with the best cosmetic result, really, that you can get from A from a burn injury. If anyone wants to take this their knowledge about burns further. There is a course called the Emergency Management of Severe Burns, E M s B. Um, and, uh, if you can book, um to go on, um, they happen throughout Europe. That just happens to be the the UK is, um, website for it, and it's all about how to treat that burn in the 1st 24 hours or so. So are there any questions? Then there are quite a few in the in the chat. I'm going to open up. I'm going to have uh, you have answered some. All right. Okay, let's have a look. Let's have a start. Let's have Okay. Um, right. Can you use ice? Hopefully, I've answered that one, though. It's cling film. We've done that. Why? If you did if you did the burned clean field circumferential e, it might as you swell. It might cause a constriction. Uh, the university contribute to the food. Chemicals. Burns is die for. Tareen. Hopefully we've done more about surgery for deep burns. Rehabilitation is, uh is slow. Um, and, um, maybe I could do another talk on that. Uh, what kind of analgesia? Uh, route on that morphine. How frequently do you dress about? Afternoon. We normally do it every two or three days. Yeah. Why can we not use gauze bandage instead of, well, goals is going to stick to your burn, isn't it? So you if you think about it, if it was you, do you want them? Somebody ripping that goes off. Um, to have a look. Occlusive just means occlusive dressing just means, um, it includes it, keeps the air out and keeps the moisture in. Uh, how do you differentiate into a dead and healthy tissue. Well, um, so fat, when it's healthy is yellow. And when it's unhealthy kind, it's a kind of gray color. Uh, muscle again. You said you can. You can see if something bleeds when you cut it, then it's going to be healthy. You also remove healthy tissue near the dead tissue where you have to remove a small margin the when skin grafts should be started after, Um, well, we like if we're a big burn. We like to try and do all the skin grafting within the first three or four days. Can you differentiate thermal burn from chemical burn by looking at it sometimes. But usually the patient is able to tell able to tell you, um, you know, either I was using this stuff and it's a chemical or they tell you as a burn. Um, have I answered, is there any other questions that I've not answered? How many layers of goes to cover the burn area? Um, why do you use adrenaline? Well, because adrenaline is, um vasal constrictor. So did you see that? That that donor site was oozing blood? So if you want to stop that using, if you put adrenaline So what you do is you Adrenaline comes in ampules. It comes in one in 1000 or it comes in one in 10,000. Um, so get one in 1000 mill of adrenaline put it in a liter of saline. You've got one in a million. And that that that is, um um good iodine idea is an antiseptic. Obviously. Um, So it will be be fine for a small burn alcohol in burn dressing alcohols. I've never heard of alcohol being used in a in a burn dressing. It's going to be very sore. I would have thought temperature of the water for cooling the chemical wound doesn't matter. It's obviously gonna be in a physiological range. I wouldn't boil the kettle. Um um Well, okay. I think we're running out of questions. Okay. Can I remind everyone to, uh, fill in the feedback form request on the link that's been posted? Uh, in the chat. It's very important to us to have the feedback. It really helps us to keep the medical school going online. Thank you so much to Professor Jeffrey. Um, thank you. And we'll just stay online for a while longer. You can you can head off unless people have more questions. Everybody. But hang on. There is another question. There's another question. Does burn caused by free on? Is that a chemical burn early on? Is that so? Is this free on? Is that like I know that some people get Is it like a cold spray? Is that what free on is? You know, like, um, um, you know, if you've had a sports injury, sometimes you spray on a cold spray. Is that What is that? What free on is, uh, in a row Can use an air conditioner. Um, I don't know. I don't know. Um uh, you would imagine it would be a chemical. It would be a chemical, uh, in. It's if it's going to be toxic fluid, that's in an air conditioner. Okay, I'm going to leave you to it. OK, thank you. Ok, Ok, bye. Bye. OK, if if people uh