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especially at this time of year. So we're kind of getting ready to look at the results Folders making a cup of coffee. And, um, at that time a dad ran in and complete panic screaming, and we just saw underneath him. And underneath his coat he was carrying his small child, who was also screaming, Not kind of sure what was going on. And we saw that suddenly that actually the child had a burn all over his face and down his chest, Not quite sure the extent. So we brought him straight into recess. Um, I just saw the kind of panic on the dad's face, and all I could see was so the child was, uh, African ethnicity. And he had kind of partial burns all the way down half his face and neck and chest. And so what we kind of gathered in a few minutes is that he was 18 months old. Um, and just before he had come in, Dad had made a cup of coffee straight from the kettle that had boiled. It was black coffee, haven't put any milk, and he just turned around, put it on a table and hadn't realized that his son had run in and then grabbed it and poured it all the way down himself. He just screamed. Dad screamed, and then he actually lived a few roads away. So just bundle him in his arms and legs, get to the hospital. Um, otherwise, he was normally fit and, well, Mom had actually gone away the night before, so he was so low parenting. Um, but there was no other kind of social concerns with him. He thought his immunizations are up to date but wasn't sure about the exact details about that. Um, so the initial kind of thought was just mainly panic panic from the child panic from the dad. And then I had kind of panic just from the beginning. Wasn't quite sure the extent of the bands. I didn't know if he had ingested any of it. I didn't know if he had inhaled any of it, and I also didn't know the extent in terms of the neck and the chest. And I was really worried about, you know, Is this going to lead to any internal bands and also airway compromise? Um, but actually, we had a great team on and we managed to kind of sub like do multitask within, Uh so everyone was doing lots of different things at the same time, So I kind of did the initial assessment just to make sure we could kind of see what we were actually dealing with. And then the S H O at the time prescribed the analgesia when we kind of realized that actually, we didn't have any acute airway compromise. We then obviously got on to do the basic first stage because that hadn't been done and obviously giving him some analgesia when he first came in. Actually, because of the bands on the face and the neck, we actually did fast bleep the anesthetist as well because we weren't quite sure how this was going to escalate. And then obviously we got the play therapist involved because the child was extremely distressed to try and help comfort them, and also so we could as a kind of a distraction. And the consultant was their clinical support, but also kind of taking the history from the parents. And then, obviously we're having ongoing discussions with the burn unit, which actually, because when I was working in the North Thames at the time. And sorry, I didn't know, Um, actually from looking at him. So he was initially screaming but didn't have any kind of airway compromise. There was just there was no strider and really, fortunately, I could see that the Burns had happened kind of on his cheeks but somehow had, like, just hit his chin and then because the way he was looking up, his chin kind of must have blocked and some of the hot coffee going around a lot of his neck. But he had done some of his neck and a third of his anterior of his chest, but it hasn't gone circumferential just the way that it had poured when we managed to actually kind of settle him down and actually get some observations. He had normal saturations and kind of his air entry was good. Obviously, his first initial observations were all abnormal because he was so distressed and trying to get a BP on him was really hard. But his heart rate, obviously he was really tachycardic. Um, we did end up doing a B M in terms of which was normal, and that was when we were doing a cannula bit later on, so that wasn't on the initial assessment. But he was otherwise, apart from distress did settle with analgesia. And then obviously, we looked at the extent of the burns and he had partial thickness, which kind of went from his cheeks, digestion and um was about 10% of his total body surface area when we worked it out. Um And I think, um so obviously you know, most people in terms of your management, obviously you've done you're a to assessment. And luckily at them, we didn't have to. In terms of his airway, we didn't need to provide any airway support. A lot of the management we had to do was obviously providing adequate analgesia. That was, that was one of the challenges. And actually because of the extent of the burns and following discussion with the burn unit, we actually also gave him IV fluids using the park and formula, which is stated there, which you give half over the first eight hours and then the rest within the next 16 hours. Also, following discussions with the burn unit, they started saying to give IV cut marks lab um I think because of the extent of the burns. But also, Dad was a bit unsure about his immunizations. So he went off to kind of get a bit more information about that, whether whether he needed to have any further kind of tetanus and things. Um, then obviously, the bands were deroofed, which was obviously quite distressing for the child. And then photos were taken. Um, and then they were dressed appropriately, and then there was kind of obviously further discussion with the burns. You know, I actually wanted to see the child at that day, but obviously, we need to make sure that he was safe to transfer to a Burns unit and how we were going to do that. So we actually kept him in recess for kind of prolonged period of time, just making sure that there was airway compromise or deterioration within the child before he sent him there. And so just, uh, this is just a pinch of the muscle burns up, which I'm sure most of you use. I found it extremely useful in the kind of element the first initial stage when it was just very stressful, with a lot of people like the dad and child screaming to work out the percentage, but also to do with the IV fluid. Um, calculations. So just a reflection of this case. Um, so the challenge is that I found was kind of the initial examination because Dad was screaming Child was screaming and actually just kind of possessing. What extent of this, you know, how well was he? What did we need to think about? And I was really concerned about what was the complications going to be? And did we have all the resources there to manage that? Because I've never had to deal with a child who had airway compromise related to burns before. Um, so it was just I was really worried. If it did escalate that we'd have the right people there and then obviously making sure he goes to the right place. Um, the other challenge was the pain control. And so he was extremely distressed. Initially, we have used things like damn or intranasal for some Children, but he was 18 months, so he couldn't really wouldn't be able to sniff it necessarily that well, but also we didn't know we were just a bit worried about what kind of exactly to extend. The facial injuries were So we ended up using just simple an adhesion or more. But we had to do a lot of we had to get involved in the play therapists and a lot of the team while he was dressing the burns and the roofing them because it was very distressing for the child and the dad. And then I think the final challenge was obviously just thinking about the safest way to transport the child to burns units. So we actually kept him for a few hours just to make sure we're happy to send to a buzz, you know, And you know, we didn't need to have any HD you or P i C u M involvement with the child. And then it was how we you know what was the best way to transport him. And in the end, we went with an ambulance when we knew that the child was fine from an airway point of view. But it was kind of like ongoing discussion with my consultant about, you know, who was the best person and the best time to do it. Um, and in terms of kind of the positive reflection. So I think everyone kind of stepped up from sitting down making coffee to kind of working independently, but together to do lots of different tasks very quickly in a kind of very stressful environment when when Dad and the child were panicking and and very obviously distressed. And I just obviously with most things when you've got and, you know, an acute emergency just the repeat reassessment just to make sure that they hadn't deteriorated. Because I've never managed a child who had, um, compromised you too Burns before. And I was just, you know, very mindful of that. Um and actually, one of the biggest positive reflections I saw the child probably a few months later, just he came to me for something minor and he had such minimal scarring. So he had a very small scar on the middle of his chest, but nothing on his face. Which was amazing considering the extent of the bed when I first saw him. And it just goes like to show that actually getting basic first aid in very early and then great management of his burns from the Burns team. What a really amazing outcome. You can have for the child, especially considering he could have had really awful scarring on his face, Um, which, you know, would have been horrible for him. So I think that was a really good to take home message for, like, me and my whole team, but yeah. So that was just the case that I thought I would discuss. Thank you, Kate. I think Nick has just gone away for a clinical call. Um, does anyone have any questions relating to that case? Um, initially comments as well. How easy was it to shower him down? Like it was just a shower? He did? Yeah. So we actually had a shower in in our rainy, So we put him in a big shower, so actually, it wasn't that bad. I don't know what we would have done if we didn't have a big shower. I guess. Um, yeah. You'd have to put him in a week or something. How long did you know? 20 minutes. So yeah, that was the other thing is that I didn't want to put him in the shower if I couldn't make sure that he was fine from a night airway. Point of view. So I had, like, my head. Just do the 20 minutes. But I was like, also must make sure he was breathing. So we kind of assessed him first as much as we could. But it was really hard to get observations on him initially because he was so upset. Yeah, it's really good you did that the water thing because that's probably what made a big difference, right? Yeah, I think so. Yeah, I think so. And yeah, great care from, I guess, the Burns team as well, with all the dressings and making sure we didn't get infected and all that kind of things. So I think Harris's having trouble. He has been I/O, and I think he's having trouble with audio. Um, I'm not quite sure what to suggest for him. Uh huh. I Should I stop saying my I stopped wearing my Yeah, I think everyone else is. Seems to be working quite well, doesn't it? I think it's quite on your Internet. Internet is not very good. It cuts out quite a lot. Yeah. So I had a few questions. So this child was it Did you say it's coffee? Sorry I missed the bit right at the beginning. Yeah. So Dad has just made a cup of coffee straight from the kettle. That was a black coffee. And then what were the airway concerns? So when you first presented, so he never actually developed any clinical airway concerns? It's just the fact that he had put it on his face and down his neck. And I didn't really know if one inhaled it or yeah, and I didn't know the extent of around his neck if it had, but actually, he never It never progressed any airways, I think it was my panic that if it did, how I would manage that Yeah, No, I totally get that. And, you know, it's a very sensible approach going back next. Swelling in the mouth is a little bit like, if I mean stuff like hot liquids if your mouth is shut and obviously don't know if it is in a little child. But if it is, actually, you can be pretty confident that what's inside the mouth is going to be absolutely fine. Um, the same extent can be true. Very quick flash burns. You know, if you kind of I don't know, barbecue or that kind of thing. But obviously it depends if your mouth is open or you take a gasp or something like that. So you're just sensible to make an assessment. Really? Um, the other thing I'm just going to say and again. So I was dipping in an outside trying to just see if we could get harassed to work. I think he is still trying. Uh, so I think Harris can hear, but we can't hear him. It seems I was going to ask Did you touch on any other types of burn? Probably not your case. But I was just going to ask if we if any of us were being a child, have been through a house fire. What would the kind of additional things be that you might think about? Yeah, inhalation burns. So obviously, if they've got any kind of, like, you know, blackness around the nose or mouth, you get very worried about that. And then I guess carbon monoxide poisoning Thinking about that? I think so. And I'd as well as something to consider with the house. But hi. Guys can have it. Uh huh. Hi. Can you hear me? Can you hear me. Okay, So, you guys, uh, my name is Irish and, uh, first, uh, you know, I'm not feeling very well. The second is I've been having some issues. Uh, yeah, I heard a lot of your presentation and things. Uh, I thought I'd share a bit of a small presentation as well, but unfortunately, I can't because of issues. So what we can do is, uh, do a bit of, like, DeNoble thing. So I heard a few questions and stuff like that. Um, so why don't you ask me questions? And then, you know, probably we can, uh, take it that way. Uh, rather than anything. Um, just to start off. Yeah, Burns is very infrequent, and when it occurs, it's very, very traumatizing. Both a child and also the medics and the nursing staff were around. Um, but it's quite a fruitful thing in that if you manage Children very well, even Children with, like, 80 to 90% burns. They survive because they don't have any morbidities. And the people who die of burns are more like, uh, you know, uh, sad, mad and bad People who die so sad. It's like people who are like, you know, suicidal bad. It's like who kind of, you know, try and do some sabotage and they get burned themselves. And mad is mad, you know, like psychopathic and in adults. The main thing is that, you know, they've got liver disease. Is they got alcoholism? They got, you know, drugs and they got obesity and all that, But in Children, it's not. So, um, most of our Children recover very, very well. And in the last five years, there's only one kid who has died of flame injuries. Um, with us who was like a flame injury of about 80% or so, Um, so to start off with all you know, most Children do recover. And before it was like if you had a burn of about 50 60% it was assured mortality, but obviously depends on where you are and what you're doing in which part of the world you are. Uh, in the UK, it's pretty good. Um, and you know, you're expected to survive as a child, even if you have, like, 80% to 90% birds. It's a long kind of journey ahead. Uh, so you know, that's the first thing. Is that what you do, make what you do? Um, as like frontline people does make a difference. You talked about the interventions. First tried interventions. Yes, we do advise, you know, kind of cooling off for like 20 minutes under tepid water. So it's not ice cold water. Just remember, because I school water itself can cause burns. So it's tepid water. You can, you know, running tap water or a bath for 20 minutes. It seems a short time, and I'm saying, but it's quite a long time, but you have to remember if it's a very large burn as well. Sometimes they can have hypothermia, so it's a bit of a contradiction in that you're asking them to cool down and shower and stuff at the same time. You need to preserve the body temperature. Yeah, so that's what he advised and usually just take plain film is fine, so no antibiotics, no honey, no cream and stuff like that. So we have a lot of Children who have got, you know, all sorts of things, like honey and cream and whatnot put on their face or wherever they are burnt. So nothing of that sort so simple things managed well, essentially. So you can just put a click film after, uh, you know, shower them for 20 minutes. But the important thing is, don't let them get cold. So, uh, you know, uh, warm tunnels and, you know, if it's a very large flame burn, uh, even, uh, you know, blankets can be helpful, and one of the main things is temperature at admission. So we have a metric, so we actually don't take Children who are adults are colder than 33. Yeah, because the mortality is very high, and it's one of the main things in terms of stabilization and that they should be warm enough. Okay, so your job is to check the temperature, make sure they've had the first aid, cover it in a clean, clean films. And you talked about the mercy side burns up or whatever it is. You know, the, uh, important thing is like, you have to open the chart. Even the burn surgeon open the charts, and then they calculate the amount of burns. Um, And when you're calculating, one thing is that you know, you shouldn't count the, um, just the red areas because it over estimates it. So red areas like sunburn. It's not burned, essentially. So if you've got, um, you know, a proper burn, then it's it's not a part of it if that makes sense, so there may be red areas, but, you know, it's not counted in in the bones. And as a rough rule of thumb, a palm is about 1% and not yours. The child's so you can kind of, uh, you know, count as to how many moms are. They're essentially, uh, to assess the burn area, if that makes sense. Uh, and then there are different formulas you calculate in terms of the IV fluids, and again in terms of the difference you make, uh, it's shown again and again that, you know, the earlier you start, the more fluids you give, not not more fluids. Doesn't like the earlier you give, or later you start that has a direct effect on the mobility and mortality. Okay, uh, when do you think you need to start recess fluids? 5%. 10%. 15%. What do you think? Anyone? No. All right. So So in the first four hours, Yeah, hopefully earlier than that in terms of Teresa strains. But how much do you give it for all Children with burns, or, you know, it sort of presentation burn, You would give it. Okay, I'll tell you, it's like, 10% in Children. Yeah, so 10% you start missus fluids. Okay. And there are different formulas as Brooklyn's and Parkland and what not, but in Children, the thing is, um, it's important to consider maintenance fluids because you just use the Parkland without maintenance. Uh, some Children who are on the ward's probably will have more fluids than a child who has got a burn of about 12% or 15%. Does that make sense what I'm saying? So what I'm trying to say is that, uh, it's important to Hello? Yeah, So it's important to add maintenance fluids to Children. Okay. And there's a fine balance between, you know, over resuscitation and under resuscitation, and it's very well known if you're under is a state or you start late resuscitation, you've got bad outcomes. But at the same time, if you overload them with fluids, that's bad as well. Okay, So generally, what we say is full maintenance fluids and, uh, you know 2 to 4 miles per kilogram per percentage burn. That's the Parkland formula. And it's usually started after 10% all right? And they say 10 to 15% you can. Usually you can manage with the oral rehydration, but usually we don't like that in that will usually anesthetized them and see what the extent of burners and scrub it off and so on and so forth. Um, so IV fluids for, you know, 2 to 4 miles per kilogram per percentage burn. I'm sorry. And, uh, maintenance fluids in addition as well. Okay, um, and in terms of how you'd titrate, there's no hard and fast rule. It depends. You know, um, the most commonly followed his urine output, so 0.5 to 1 miles per kilogram per percentage. Bonus the urine output you need to follow. Um, and you know, just kind of, uh, make sure that they're being usually about 10 or 20%. It's okay. You don't have to kind of go really gung ho about it. But when you start stepping into major bones territory, which is more than 30% make sure you've got a catheter and you know the other markers of adequate resuscitation. Sorry. Like lactate And, uh, you know, heart rate and BP. You're not. So they're all there. But in burns issues like if you've got a very big burn, about 40 50% and they're bound to be high, you know, take narcotic. Uh, they will have, you know, like a hyper inflammatory response later on. But for all practical purposes, uh, these are the combination of measures you should take in terms of lactate heart rate, BP and adequate urine output. Um, so those are the things you're gonna look at in terms of seeing whether you're devastating your child well or not. Okay, Uh, in terms of Canada's and stuff you need, like, white ball, Canada's at least two of them if you can get them. Um, and if you're you know, if you're really sick, child, about 80% 90% burns. Whatever you can put in trashes, and you can put a central line through a burnt area. Try not to, but if you don't have anything and interesting center, central line through a burnt area is fine as well. If you don't have any choice and starting just a station early is good. So you calculate the Parkland formula, which is 2 to 4 miles per kilogram per percentage burn after, um uh, and you add maintenance fluids and that's worked out for 24 hours. The first half, you give it over eight hours and the second half, you give it over 16 hours. And there are other variations of, you know, formula like biggest body, surface area and apps and stuff like that. But the basic principles that and the most important thing is titrating. Um, and if you need to give bolus is because of a particular reason it's okay, Um, as in like, you know, you're hypertensive and you like it as high. You can give a bolus, but otherwise it's usually not necessary. But obviously, if it's a large burn and stuff, you may need to kind of resuscitate them. All right, um, so make sure they're not cold, right? Um, you know, make sure their warmed up as well. So in the burn unit, you have got special warmers, believe it or not. And when they come, you know, the patients have got a kind of a, uh, thing which hangs like operating theater lights. They got a thing which hangs down and you know it's It's about 34 to 35 the rumor is really, really hot. Okay, so about 38 29 so they don't lose temperature and adequacy of temperature is one of the most important metrics of whether they will survive or not in very big birds. Um, so we talked about fluids. Antibiotics? You don't need any antibiotics, Um, because it's usually sterile. And sometimes, you know, if you do give antibiotics when you're scrubbing them as like a preoperative antibiotics. But burns is one area where we are very, very vigilant about antibiotics. All right, so we don't give it randomly. And if you give it, it's for a specific reason and you stop. Otherwise. What happens, especially in Burns, is that you've got a colonization of bugs, right? So if you keep people on antibiotics for a long period of time, you are going to get very, very resistant bugs. So we we kind of take pains to differentiate whether it's an infection or it's a colonization, and, you know, if there's a colonization, we don't tend to treat that. But if it's an infection. We do a sharp short course, and we use other measures as well as in, like shoving them, uh, dividing the dead areas and so on. Okay, so no antibiotics on this, it's actually needed. Um, so those are the initial parts, which I kind of, uh, you know, thought are important for you guys on the front line. Right. Um, the other thing is inhalation injuries. Right? Um, so probably once in your lifetime, you're going to get a child in a major burn. Um, and inhalation is a big component of your mortality and inhalation. You can kind of, uh, divided into, you know, upper airway and Lower Airway. Uh, so essentially, the initial airway swelling is because of upper airway. All right, So some of them, if you got a superheated environment, is what they call it's quite, you know, it's got a lot of toxins. It's got temperature. It's called carbon monoxide. It's called Sinai and whatnot. Right. Um, so other than that, you know, it's just the heat of it, and it affects your face and also the supraglottic area. Okay, So, essentially reflux reflects the what happens is the child or the adult closest daughters, and it's usually not transmitted the super heat down. But of course, you know if it's a blast injury, it goes beyond your vocal chords because it's forced apart. Or if you're there for a long period of time, it kind of goes down as well. But this is the first type in terms of the supraglottic injury, so it's going to cause a lot of edema and injury and swelling so early Intubation is definitely advised. Um, and we tend to extubate them at, like 48 hours, $70. The other thing is like the lower airway injury. Just call the, uh, inhalational injury. So what we usually tend to do is bronchoscopy. The child you describe doesn't require one because it's a scale. Um, and if it's a injury in a closed environment, like a flame injury, um, like you've got furniture, um, and other things which in it Sinus, carbon monoxide and whatnot, you have to do a bronchoscopy. It's not urgent. Usually there, okay, in the 1st 24 hours or whatever. Um, but your job is to see what the carbon monoxide level is. Does anyone know what? What is the toxic level of carbon monoxide. So you want it below three? Uh, yeah, that's right. I mean, some smokers tend to have, like, 3 to 5%. Uh, you know, more than 10. It's supposed to be toxic. 20%. You essentially dead. Okay. And it's very important to see the carbon monoxide level. Uh, there's nothing you can do about it other than 100% oxygen. We tend to advise 100% oxygen till your carbon monoxide level is less than about 5% or so, uh, like 5 to 10%. But it's important for prognosticating to see what it was. And it's a time dependent thing because it will decrease, uh, with time. And if you give oxygen, it'll decrease more quicker. Hyperbaric oxygen makes it disappear a bit more quicker. But we don't have hyperbaric centers in the UK because, as I said, simple things done well as better than nothing. So the logistics of challenges of you know, super super hyperbaric oxygen. Uh, I'll do the other things in terms of, uh, establish, you know, cooling for 20 minutes, making sure they're not very cold. Adequate IV access, uh, ensuring that IV fluids are given very soon and so on and so forth. Okay. Um, yeah. So that's about inhalation. So what usually happens is about, you know, other than carbon monoxide, uh, for which you got just going to give oxygen. There's nothing else. You can give that side as well. So cyanide. It's more like a diagnosis of, uh, consideration because you can send cyanide levels, but it takes over to come back. Sorry. So, cyanide. It's more like, you know, if you got if you're adequately resuscitated someone, but you've got a persistent like it more than four and you got a difference, like arterial venous difference of more of less than 10%. Then you have to strongly think of cyanide, obviously in the scalp or in an open field. You wouldn't think of it. But you know, if there's furniture and stuff like that, and your resuscitation measures are not doing very well, then you do what is called a Sinus kit. Does anyone know what sign of it is? It's in the name. It's like a reversal. I know there's one in Saint George's any, but I don't know what it is. Yeah, it's it's It's essentially cyanocobalamine. Yeah, B 12, right? So it's a big dose of vitamin B 12, so that's 70 mg per kilograms. The dose, if I remember it, right. And what it essentially does is it binds the cyanide and, you know, it makes it into, uh, sign a scopolamine and you pee it out into a compound. Yeah. So if you've got a high index of suspicion of Sinai toxicity in terms of how very high Lactaid and any difference which is not coming down despite resuscitation than you consider, um you know, um because I know a kid, Um and usually what happens is there's a R d s in the 1st 48 48 hours or so. So we use what's called an inhalational protocol. You don't have worry. You don't have to worry too much about it. But it's a combination of Estyle 16, um, heparin and, uh, broncodilator, essentially to kind of, uh, make sure that the, um, the suit and other things are cleared off. Right? Um, so other than carbon monoxide, which you're going to treat 100% oxygen till it comes down and the cyanide, which you're gonna have a high index of suspicion If you've got a very close environment and there's people dead and this furniture and other things around, you'll give sign, uh, sign A compliment. No sign of it. There's nothing else you can do in terms of, uh, other toxic things, because that's the only thing we see. But there's loads of other things like, you know, sulphur and other things that are very, very toxic so that you can't measure right. So those are the things you can do in the initial phase, right? So make sure they get 1st 1st aid. There's criteria for referral as well. For the NSC. Be sorry. LCV website. You can go through it as to who with Children need to refer to the bones. Surgeons and, uh, start fluid resuscitation after 10%. Make sure that they're adequately warmed. I know it's it seems stupid and that, you know, we're talking about burns and I'm staying warm them. But that's the nature of the beast. Make sure they are not hypothermic, because hypothermia has got bad prognosis. No antibiotics, no honey, no creams, nothing. Just a clean films. Fine. And when you're putting clean, we'll make sure it's not like constricting the blood supply itself. Okay. The other thing is, you know, in very big burns get your plastic surgeon to have a look If it's circumferential uh, you know, sometimes they may need to do what's called an escharotomy before they leave your transport service in very big burns. Right? So get them to talk to our surgeons, and they can, uh, you know, advise as to whether, uh, scrotum is our needed. Otherwise, you're gonna lose the limp. Um, one more thing. If you've got again a very big burn, the whole of the tracks, a confidential is involved. You may have to do a escharotomy before you leave. Otherwise you're not be able to ventilate oxygenate a child. It's These are all very rare things. But they do happen. Okay, um, that's about it. And if anybody has the fortune to come to our unit, uh, it's, uh it's almost like a Formula one kind of a thing. So we take the Children in a receiving room, so we pay them. We kind of have a port which says how much they ever see what they see, and we go through a B, C d a. Um, and you know, we assess them, and what happens is our surgeon comes and the, uh, reassess the percentage of burn, which is the land broader chart. And they make sure is it, uh, the correct burns? A lot. As I said, Just being a bit hyper, um, it doesn't mean it's burnt. Um, and then we see whether we need to catch up fluids and anything else. We You know, the surgeons are quite brutal. They just cross it off, and then they cover it with some sterile dressings. And what they do is the next day they see which part of the skin is Waibel or not. So the ones which are viable is the ones which will grow. So that's the degrees of burns. Okay, so in America, there's like, first degree, second degree, third degree, four degree. We don't do that. Um, so they're superficial. Uh, there's, uh, superficial dermal. That's deep, dermal and dermal. So the first two I mentioned, uh, superficial, and they heal by without grafting. The other ones need a grafting. Sorry. Autografting, which is your skin. So essentially they strip off the skin from other areas and they put it on things which will heal, but we'll take a very long time, and that will heal with secondary intention, scarring and infection and so on. So it is a bit not, but this was in 19 forties and fifties. They did that in that they found that if you take healthy skin from elsewhere and then put it on the burn skin, your chances of survival lot better, even though you're causing a wound in the other area and that will heal and the deep ones will heal as well. And of course, if you got like 90% or 70% burnt, your options are a bit limited. So in that case, uh, use allograft for, for the time being, and you also use like, mesh craft. So what you do is you take the skin and put it to a measure. There's like one is 241 is to six meshing, Um, so it's like crisscross fibers and you try to maximize it. Most of our Children need multiple, you know, grafting sessions. There's issues with pain and sedation, but we are quite good with our sedation and pain protocols and so on, so hopefully they shouldn't be traumatized but we have every now and then Children who come from abroad who are very, very traumatized because of inadequate pain management. So pain management is an important part as well. So morphine as your friend, Uh, not personally, but, you know, for the child. Um, so make sure the NLG cr is adequate, etcetera. Okay. Um, yeah. And then, you know, it's a very long journey. Roughly we say one day of hospitalization for every burns. So if you can imagine, you know, if it's a 50 60% burn, they're going to say if it does for a long period of night and, you know, I got a fantastic physiotherapists, fantastic dieticians, which are all an important part. I won't go into the details of how much you feed water and whatnot, but, uh, those are important aspects, okay? And I talked about microbiology. No antibiotics, unnecessarily. That should hold out for all your patients as well. But we are very, very militant about it in Burns unit and that we stop it and we don't start, and this is actually needed. Okay. All right. I've been monitoring, and I think everybody is going to sleep. Um, ask me questions. Okay, You have to leave a long pause for the questions to come or wake up, I guess. Yeah. Thank you so much for your talk. A question that I had is Does it matter what kind of liquid it is? For example, I remember getting her presentations. He said it was coffee without milk. Would it make any difference if there was hot milk inside as well? You're asking whether the type of liquid burn makes a difference? Yes. No, not really. I mean, the oils tend to kind of, uh, you know, penetrate a bit deeper. Most commonest calls. It's just like tea and pans and cooking and so on. Um, so actually it doesn't, But maybe if it's like a okay, oil, it's by the temperature. So there's, like, a temperature scale and duration. So there's like a chart and the likelihood of injury. Um, so I can't remember what it's called, but the heart of the liquid and short of the time, the more chance of injury. But, you know, the basic management doesn't change and that you're gonna call the child with interpret water for a period of time, doesn't answer a question Yes, Thank you. All right. Anything else? So you're going to get a child, you know, once or twice in your life with major balance. And, you know, the thing is, it's like it's very infrequent, but when it comes, it is quite traumatizing for everyone because it's it's unfamiliar by the nature of it. Okay, so you have to have some sort of a idea what you're doing and your l S E B n, which is like the London Southeast Burns Network website is very good. It tells you what to do, what not to do when to intubate and stuff like that Usually, uh, I forgot to mention incubation. It's needed early, especially if it's a flame injury, enclosed space and stuff like that. Usually, schools don't require it, but, you know, talk to our doctors. We can kind of guide through it. But we're not prescriptive because, you know we can't because the child is with you. And you know, if you think the child needs intubation earlier is better than later. But there's a fine balance as well, in that we get a lot of Children who don't need intubation, and they come intubated without reason. Um, so it's like a fine balance. We're happy to kind of advise you. And on the TPN, they say, which kind of things need any protection and so on? You can go through it. Okay. Mmm. You with chemical bands much as well. Yeah, I think chemical once in a while, Not in Children. Usually it's usually these industrial accidents, which is a chemical burn, And in that, um, you know, again making sure that it's neutralized, adequately shower and stuff like that, um is very, very important. And I don't Don't try to neutralize acid with alcohol and so on, because it causes more, uh, chronic reaction and some of the industries which you may have chemical burns to have a liquid called Dysport. Different train, I think, which is, like, a neutral solution to help clear it. And sometimes you can use a litmus paper to see whether the acid oil clears neutralized or not. Um, so it's just adequate, you know, cleaning. Essentially. Yeah. And, uh, yeah. I mean, on the l S e b. And they kind of give you as well, it's infrequent. Uh, so you know, some of the powders and stuff you're not supposed to put water. You just dust it off and, you know, don't use acid, uh, likely to neutralize each other. Uh, so it gives very good common sense things. So l s e n is your friend. Go through it. Yeah, and I think more commonly, we get electrical burns in adolescent, you know, Children who are, uh, messing around and stuff. Claire's. Just ask a question. Any advice that securing et tube with facial burns use ties in case of facial swelling and movement of the E T. That's right. Uh, usually ties. Obviously you can't use, uh, you know, your, um your usual, uh, strapping techniques. And actually, I thought, it's not a big deal in that most of your adult intensive as an adult, any people, they use ties. So ask your friendly adult intensive wrist or your adult, uh, any person they will know how to tie it. It's usually ties are fine, but of course, you don't have a facial brand. You can use the usual one. Do you give them takes methadone with if they've got the inhalation burns on or not, Really, if you can use them fine, Short answer No, but maybe just before excavation are those also, but no. So we use the inhalational protocol, which I mentioned combination of salbutamol, any style sustain and heparin. Uh, there's no, you know, it's not like they try to do a study, but, you know, that's what we use. And it may work. I think sometimes anything else guys. So we are based in Bloomfield Hospital transferred, and there's an interesting history as to why it is. They're apparently It was started during World War Two because London was getting bombed everywhere, and it doesn't make sense to have a burn hospital in the area where you like to get burned. So they put it out in Brookfield, which is in Essex. It's called Saint Andrews Burn Center. It's been there for decades. Uh, they do a fantastic job. I'm not gonna go into the details of the logistics and politics in terms of whether it should be there and stuff like that. But what I would say is that you know, intensive care is a small part of it. The other things are super important in terms of a dietician. Who knows what he or she is doing a physiotherapist who knows what they're doing. A psychotherapist and and, of course, burn surgeons and Children's bones are so rare that you can't have a separate Children's burns. You know it. It has to be called located with adults. And, you know, some people go very gung ho saying, Oh, my God. You know, I got I got a child with It was intubated in a not to pick you, but I think, in my opinion, uh, it is stupid to consider it that way because, you know, uh, they're going to be intubated, like a short duration of time. But the other things are more important, right? In terms of, you know, managing the burn, you know, making sure they are resuscitated, adequately, etcetera. But that's a that's a conversation for another day. But, you know, the, uh, I thought I'll just put it out there and of course, you're more than welcome to come and visit us. Um, they may or may not be Children. Uh, there will be adults, and you can have a look at what they do. Is there like an age cutoff? A baby who's so, uh, 3 to 6 months is what we say so again. Broomfield the necessary Fantastic. They would have done some Children, but you know, they get a bit queasy when it when it's a 3 to 6 month old child, in which case they will go to Birmingham. Uh, and it's very, very infrequent. Yeah. Harris, that's super. Thank you. I'm sorry. Uh, you really shouldn't have done this, but really kind of sorry, but we could let you go, to be honest and go and rest up and hope you feel better soon, but really appreciate it on behalf of everybody. Yeah, no worries. If you guys want to come and visit or if you want to email me with any questions, uh, you can put on my email. I'm more than happy to answer it. All right. Super lovely. Thanks. Harass some things get better. See you. Thank you. And ls CBN remember that? Okay. Thank you. Take care. Bye. All right, I'll just pop. She's email there in the text of lovely to everybody. We've got a nice little group, actually, I'm glad people could turn out Lottie, Thanks so much. You just plug next month. Uh, next month is tracheostomy. Uh, if anyone has a tracker case and wants to present rather than always being me. Then let me know. Otherwise, I've got one that I can use, but, um, and then we've got a speaker. Joy, who's the tracking nurse at ST Georges and knows a lot about that. So, um yeah, let me know if you've got a track in case that you want present. Um, but yeah. Tracheostomy next month. Wonderful. See you very soon. Thank you. Thank you. Thank you. Yes, thank you.