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Hello, everyone. My name is Ria and I'm part of me support team. It gives me great pleasure to introduce our speaker for today on plastics and reconstructive surgery. Um Mr Baljit Denson. Then there we go. Um And basically what I'd like to encourage you to do is ask any questions you have in the chat. He's lovely. He's a plastic surgeon from Southern England. Um And um, I'd be quite happy for you to take it away. So, um go ahead and I'll just ask you any questions that come up in the chart and please do ask questions. Brilliant. Thanks very much Ria. Um So yeah, I'm a, I'm a burn surgeon in um in the south of England in a place called East Greste, which is a small town south of London and he's got a long history of burns care. Um And hopefully, what I'm gonna try and do is give a brief overview on um on burns which is relevant to, I think a much broader population. I think one of the big issues is um depending on the health care system that you are in. Um There are sometimes lots of resources and sometimes there are not very many resources at all. And I think um one of the things that I really want to try and do is get through the basics and then we can go through in some more detail through your questions. Um Any, any topics you may want that are specific to your particular area or expertise. So, what I'm going to do is I'm going to start our presentation. Um and hopefully we can um, get through this with a little bit of time to answer questions at the end. Uh I'm hoping to, to cover as much as I can, but we've only got an hour to cover pretty much everything that I do, which I've learned over 20 years as a consultant. So you'll have to apologize, I'll have to apologize if I don't cover everything. Um, but equally if I don't give you as much detail as you want. So we're gonna focus on major burns and um I'll start off with the initial management, um, er, really focusing on the general management that any major trauma and major burns are a major trauma. Um, have to go through then talk specifically about burns assessment, talk about the initial treatment that we would give, um, talk about some ongoing treatment, um and then talk about infection and psychological support. Um One of the things um that we probably don't do so much as um clinicians is talk about first aid and I think the really important thing to take on board is we need to encourage, um, everyone to be able to give good first aid. Now, sometimes that's easy and sometimes that's difficult. If you've got running water, that's not too cold. So tepid, tepid is, I suppose, you know, slightly, um, cool or, um, not hot, obviously, um, water, um, then running any burn under 20 under tepid water for 20 minutes is really important. Um, and that can bring about benefits. It stops the burn from becoming deeper and you can get benefit even three hours after the original injury. The important things to understand though are patients can get hypothermic, especially if they're Children and Children really need to be kept warm in the other parts of their body. If they are getting that um uh level of um first aid, uh especially if it's a large burn, it's also the same for chemical burns. Sometimes people talk about antidotes and the like, but generally for most burns, whether it's chemical or flame or scald, um 20 minutes of running water. And if you can't do that, then wet soaks constantly change to try and cool the area. And then once you've done that you need to cover the burn wound. Uh There's something called cling film that's this clear plastic stuff or um food wrap, they sometimes call it or saran wrap. Um putting that on the burn before it comes to hospital is really important because it stops it being exposed to the air uh and provides a degree of pain relief. The exception to the case about the running water is that specifically for Hydrofluoric acid. Um There are particular antidotes and we'll talk about those at the end of the lecture rather than at the beginning. Um Before I go any further, I'm a great advocate and a supporter of Inter burns, which is something that I think every person um who's doing burns should be aware of. And if you can see the website, it's inter burns dot org forward slash training and the manual, they've got called essential burn care. Pretty much covers everything that I think you need to know, to be able to provide good quality safe burns care in pretty much most health care environments around the world. And it's specifically aimed at areas where sometimes healthcare is um resource limited and um it provides practical solutions um because not every hospital has super specialists and millions of dollars worth of, of funding. Most importantly, it's free. And um there are a lot of resources on the uh on the internet and you can download the manual, essential burns care. Uh And I read it just as, and I try and encourage my trainees to read it too. So when a burn uh that's large comes into your uh hospital, um you've got to treat it like any other major trauma. So um there's the ABC D of um major trauma that looks at, looking at the airway and the cervical spine, looking at breathing, looking at circulation, looking at disability, um, exposing everything and making sure that um, the environment around them is kept as safe and as appropriate as possible. And then we're really looking at starting to manage them. So, painkillers, fluids, doing various tests and then doing what we call a secondary survey and specifically for, um, burns, the airway can be affected because of, um, the burn causing facial swelling. And we'll talk about that a little bit more. Um, it may also be because of inhalation of smoke, um, or it could be because of uh, carbon monoxide or cyanide poisoning. And we'll talk about those in a little bit more detail. But the important thing is you keep on checking this and so burns patients once you're happy with their cervical spine, uh, you try and sit them up as much as possible if their face is burnt to help reduce the swelling. Um, and then you, uh, look to see if there's any so in the airway to see if they're speaking, ok, if they can speak easily if they're breathing easily. Um, and the breathing easily is really about, um, if they've got burns on their chest, um, is that causing the restriction, if that's causing the restriction? Uh, what needs to be done because if they can't, if their airway is ok and their breathing is not, they're still not in a good position and we need to often consider surgical release if you've got a very tight burn causing restriction. The other thing you need to do then is also get intravenous access for a large burn. Um And at that time, you can also take blood tests for a full blood count, uh urea and electrolytes and creatinine to check on the renal function. And um uh potentially also um get a group and save to potentially cross match blood if it's required. Um um but sometimes getting a line in is not as easy as you imagine, and we'll talk about that as well. Um Disability is really more about assessing what's there and, and that starts focusing on the, on the burn itself. And again, we'll talk about that. Um And so in the first few stages, it's about making sure that the patient doesn't have any life threatening problems with their airway, their breathing or their circulation. Have they got a pulse? Have they got um circulatory access? Um Can we record their pulse and BP? Um And then um it's about looking at everything else. And so again, a secondary survey is important, don't forget that they, they may have come in with a burn, they may have had other injuries and in amongst all of this, you've got to remember the patient is scared, they're not sure what's going on. There's lots of people around them, they may have taken some time to actually get to you. They may have had quite a lot of difficulty, um, during the injury and, um, they may be in severe pain. So please don't hesitate to give them pain relief at, at the earliest possibility. Um, and secondary survey is really important. Um, if you get a history of having to jump out of a burning building or if they've had a big explosion and these two pictures really show you, um, a pelvic fracture of someone that was involved in a house fire who jumped out of the first floor window and it was missed at the original hospital. And when we reassessed the patient in our burns unit, we discovered these two pelvic fractures. Now they're fairly stable and we didn't need to do anything major about them. But you can imagine if you have a big pelvic injury, the patient may end up exsanguinating before you even get to treat the burn. The other thing is, don't forget to look in the eyes, especially with facial burns. And this picture shows a fluorescing picture of a corneal burn because it's all very cloudy. And what that highlights is, um, you may miss this um, two or three hours later because the eyelids become very swollen. So look in the eyes, look for any um fractures, look for any other secondary injury. Um because if you, if you miss that at this stage, then they may end up having problems later on so we'll focus a little bit on the burn now. So, burns come in various depths. And, um, you can see examples uh, here. So, er, right at the very bottom you see a man with just some red skin and that's erythema. Um, erythema um, is like sunburn. Um, it doesn't actually cause any blistering. It's a bit painful but it's not actually a burn and so we tend not to treat it with anything other than, um, good advice, telling them to drink a lot and giving them painkillers. Um, but the picture above it is a young lady who has had a significant scald injury and you can see the skin's being blistered, it's quite extensive and, um, the underlying skin is quite pink. So, and the same with the baby that you see on the right of the slide which shows a pink, um, blistered, um, and often blanching skin. So these are what we call superficial, partial thickness burns and superficial, partial thickness. Burns are very painful. They are uh blistered, they are blanching and often, um, will heal with dressings as you get deeper. Um, you'll have what we call deep dermal burns. And the blue circle highlights uh the area of a flame injury where the, it's not quite so pink. Um There's a bit of redness to it and if you pressed on that skin, it might blanch a little bit, but the sensation is not so good. And so that's what I would call a deep dermal burn and that's unlikely to heal quickly. It's likely to require um skin grafting if that's available. And if that's not available, it will take a long time to heal and cause a lot of scarring. Lower down in the red circle. You can see uh what we call a full thickness burn. It's very leathery. It's got no sensation and um that will cause significant scarring, take a long time to heal and would benefit from skin grafting if available. So, deep dermal burns and full thickness burns need to have skin grafting if at all possible because they will take a long time to heal and cause lots of scarring and often deformity and contraction um which can then limit function. Um as you can also see in this patient, this patient at the on the upper part of his chest has got a superficial partial thickness burn and then he's got a deep dermal burn and then he's got a full thickness burn. So often patients do have a mixed picture of depths and they can often change within 48 hours. And when you look at this gentleman, he looks like he's got quite a superficial partial thickness burn. It's blanching, it's been blistered. Um but 48 hours later, it looked much paler. Er, it didn't have such good sensation and actually had become a deep dermal or full thickness burn. So, um it's important to understand that the depth of a burn can change over the 1st 48 hours. It's also important to understand that a superficial partial thickness burn is blistered, pink and blanching. And these are likely to heal with just dressings, but a deep dermal burn or a full thickness burn, um which usually have lower sensation, um no or poor circulation on blanching. Um These are much more likely to require uh skin grafting. Uh And if they don't, they will cause significant scarring and contraction. So, after we've looked at the s the, the depth of a burn, we also need to know the size of a burn. So the depth of the burn helps you decide what treatment you're gonna get. Are you gonna address it or you gonna s er skin graft it and the size of a burn will help you decide. Um two or three things. One does the patient need uh formal fluid resuscitation? Do they need to be given intravenous fluids to be able to um stop them from getting burn shock because lots of large burns will lose fluid and over a certain size. Uh That's a significant risk. Now, there are lots of ways of deciding how uh large a burn is. So you can use um the size of the whole palmer surface of the hand. So that's fingers and the palm. Um and that's roughly 1%. Now, that's going to be the patient's palm and fingers, not yours. Um And you can work it all out by just using that as a template and measuring how many palm hand sizes there are. Um, if you've got a very large area, then you can use the rule of nine, which is basically, um, a whole arm and hand is 9%. Um, the front of thigh and leg and foot is nine per, er, 9% and the back is another 9%. So the whole of the lower limb is 18%. The other one is 18%. The, each arm is a whole of 9%. And then you can treat the trunk really as, uh, as 18% on the front, on the back and then roughly that on the front as well. Um, the, the size of the head, um, again, roughly 9% but again, you'll realize they don't all add up to 100%. So there, it's a good estimate but you don't have to go by it. Um, there are certain charts called London Browder charts and you'll see an example of this here where you can look at each of the areas and then work out how large a burn is. Um, it's important also to understand that children's proportions are completely different from adults. So, for instance, the whole of the head of, of a, less than one year old, um, is almost, er, 20% it's like 18 or 19%. So, so 1/5 of their body surface area is their head, whereas like in an adult, it's about 7%. So, um, you know, you, you've got to be really careful about looking at what the proportions are in Children compared to adults. Um, the final thing is you can use technology. So there are a lot of apps out there and there's something called, I think the Euro Burns app, there's something called the Mersey Burns app. And often what you do is you just draw on the, the screen of the app and it will tell you roughly what the size of the burn is. So, um, the size, as I said, helps you decide whether a patient needs fluids or not. And the important thing is before you can get fluids in, you need to get Cannulas in and Cannulas need to be put in. Usually they need to be wide ball. So a large cannula and peripheral cannulas are fine. Um But you need to try and find somewhere ideally that's not burnt because there's a higher risk of infection. But if that's not possible, you go through burnt skin and um if you have to, you can use intraosseous needles in Children. Um or you may have to do a cut down or you may have to think about a central venous access. So this gentleman, you can see his best access was in his right femoral vein because we couldn't find a decent vein elsewhere. And it was only once we'd resuscitated him that we were able to find other places to cannulate him. But you've also got to remember there is quite a large area of his body surface burnt. And so it becomes very difficult to find veins in burnt areas, generally, um in, in the traditional world, um if someone who is an adult had a 15% body surface area burn, so to give you an example, if someone's burnt the whole of their right lower limb, that's 18%. So that would be something that you would give them fluid resuscitation for. And if it was 10% in Children, that could easily be um if it was a large part of their head and face. So um 10% and 15% 10% in Children, 15% in that in adults was the traditional thing. But as we've learned more and more, we've found that in many healthy patients, you can give a lot of that fluid orally and it shouldn't just be plain water. Ideally, it should have some salt and some sugar in it and they can drink that um, orally rather than give them intravenous fluids. However, beyond 20% in adults and 15% in Children. And when I'm talking about Children, I'm really talking about under 10 years of age and especially under five years of age, then, um you really need to think about giving them intravenous fluid. And most people would use the Parkland formula, which is using crystalloid and ideally not normal saline because again, normal saline has a lot of sodium in and that can cause problems if you give patients too much sodium. So a much more balanced solution. So ringer's lactate is probably one of the common ones. Um we use something called plasma light, but it has about 100 and 35 millimoles of sodium rather than 100 and 50 millimoles of sodium that you get in normal saline. Also normal saline is quite acidic. Um So again, the other crystalloid solutions tend to be uh more tolerable. So you give someone two mils per kilo per percentage burn. And what that means is from the time of the burn injury, not from the time they came into hospital, but from the time they came into the uh from the time of the burn injury itself, you um you give them, you work out that formula. So two mils per kilo per percentage burn. So let's say to make it easy for me, they have got a 50% burn and they're 100 kg, that's uh 5000 plus times two. So that's 10,000. So that's 10 liters of fluid that that person needs. And the first half of that is going to be in the first eight hours. So if they come to your hospital two hours after the original injury, you need to give that um fluid half of that fluid. Um So five liters in the six hours that are left of that eight hour period. I hope that makes sense. So give half of the fluid you've calculated in the first eight hours and the second, um, half of that fluid over 16 hours. Now, there's no point in giving that fluid if you don't know if you've done effective um resuscitation because you, they may need more than that fluid or they may need less because they may be drinking quite a lot of fluid at the same time. So you need to check their urine output and the best way to do that if you're, especially if you're giving intravenous fluids is to, you put a catheter in and you measure the urine output and really, it needs to be in adults, half a mil per kilo per hour. But in Children, you'd probably aim for one mil per kilo gram. Um if you're getting too much urine output. So let's say it's two mils per kilo per hour. Um then I would reduce the amount of fluid that they're getting. Um, if they're uh producing less than half a mil per kilo per hour, then you need to increase their fluid rate. So, rather than give them bonuses, it's far better to give an increased rate and I'd increase it by 25% and see what happens. So, um airway and inhalation, um, flame injuries especially can cause problems in three ways. They can cause facial swelling and you can see that in the man in the picture here, he's got facial swelling. Um He's got so around his nose and so he's at high risk of um having problems with his airway and with smoke inhalation. So the airway can reduce air flow. Um you can get smoke deposited in the lung and that can interfere with gas exchange and that often reaches its peak at about 48 hours. And you can also get systemic absorption of carbon monoxide or cyanide. Now, if you get carbon monoxide that preferentially binds to hemoglobin, and so it effectively makes you hypoxic. Even though you look pink and traditional oxygen saturation monitors will record 100% saturation even though um they have got very little oxyhemoglobin. It's all carbon monoxide related carboxyhemoglobin. And the way to avoid that is to give them 100% oxygen to try and um push off that carboxyhemoglobin and turn it into oxyhemoglobin. The problem with cyanide um is that it's one of the side effects of burning lots of furniture. Um So um in house fires where there's furniture burning, you can sometimes get cyanide poisoning and that will stop your respiratory system, your oxidative respiratory system. And patients who have that are usually hypoxic on their blood gasses and they often have a very low ph and they have a very high lactate on their blood gasses. So, if you get that, the only solution is to give them as much oxygenation as you can and that may need intubation and ventilation, but it may also require uh antidotes. And the only good antidote is something called hydroxy cobalamin. And um that's quite expensive, but you often without that don't get adequate uh address of your cyanide poisoning in the patient may not survive. The other thing about um airway problems and especially when you've got some facial burns is as you start giving them fluid resuscitation, they become more swollen. So, the really important thing is you keep observing them. So keep their head up and their oxygen running and if they start becoming worse, if they wheeze, if they have stridor, then you will need to consider intubation and ventilation. And an experienced, um, anesthetist is vital in this situation. Um, and the reason why is because you can get enormous problems with the airway if you don't protect it quickly enough. This is a patient who came in with severe facial burns. Um, he was maintaining his airway, but as soon as they started resuscitating him, his face swelled up, they couldn't open his mouth and they had to put in a nasotracheal tube and he was close to having to have an end, er, sorry, um, um, a tracheostomy. Um, and that's something that no one wants to do. Um, the other thing you'll notice is that, um, the tube in this patient was very short and you should always try to make sure the tube is as long as possible to cope with facial swelling. Once they have been intubated, if you think that they have deteriorated and they can't maintain their own airway, then bronchoscopy uh to look at how much soot is in the airway and to wash it out as best as possible and then giving regular salbutamol nebulizers. And uh we always consider giving n acetyl cysteine nebulizers or heparin nebulizers, which will help break up the soot within the lungs. So just to summarize where we are, um treat patients as if they're major trauma. So the A TLS kind of approach, look at the airway, make sure you reassess it. And if need be, consider whether they need to be intubated and ventilated, um put in a nasogastric tube and we'll talk about that a little bit later on. Um put in an IV line and if they have a suitably large burn. So, uh in adults, um, 15 to 20% start resuscitation fluids and put a catheter in. Um um make sure they've had first aid, make sure you've identified any other injuries and then um make an assessment of the size and depth of the burn because that will help in terms of the fluid. But also in terms of what surgical or nonsurgical treatment you're going to have. And one of the things that you may not be able to get to quickly enough is if they're not breathing adequately. So let's say someone's had to have intubation and ventilation because of difficulties with their airway or breathing, if they're still having problems with their breathing and they've got a deep chest burn, um, that may cause restriction and they may need to have an sclerotomy. Now, an sclerotomy requires, um, surgical release. And the best way to do it is to probably use cutting diathermy, um, because it will bleed and you need to cut through the, the burnt skin to healthy fat, um, and release it enough to allow breathing to be adequate or to release the limbs. Um, if they're tight and you can see, um, in the upper picture here, this patient's got a full thickness burn over his wrist, um, and dorsum of hand and that needs to be released because it's causing circulatory problems to his fingers. Um The middle picture shows uh what I would say is a really bad sclerotomy because it hasn't completely released all of the skin. And um, it was done under local anesthetic. We in a room off of the emergency department and it caused too much pain. Ideally, you need to use a general anesthetic to release them. But if you don't have that available, then local anesthetic, but make sure you release the skin adequately and it pins apart. So you can see the bottom picture does show quite how much the skin um falls apart when it's deep and it's contracted. And if you don't do that, it will cause compartment syndrome, which will then need to have a fasciotomy. The other thing I was gonna point out is with the hands, even if you do an Cleo toy. The other important thing to do, especially in the hand is to release the muscle compartments through those dorsal and thenar eminence incisions so that you release all the small muscles of the hand because they are very prone to getting compartment syndrome and will cause functional hand problems. So, if you're doing an sclerotomy of the hand, um release the small compartments of the, of the hand, but also do a carpal tunnel release. Um The picture below is actually a fasciotomy and this is a fasciotomy along with a carpal tunnel release. Um that's associated with someone who's had significant electrical injury and we'll talk about that a little bit later on. So just to summarize, um once you've initially uh assessed the patient um protected their airway, um started their fluids. Um You then need to look to see whether there are any adverse effects of the burn itself. Uh And that's often restriction of breathing or restriction of circulation in the limbs. And if you see it, then you need to surgically release ideally with cutting diathermy, but if not with a scalpel, but you need to have some form of um coag coagulation control be that clips and ties or diathermy. If you don't do an adequate sclerotomy, it can cause problems further on down the line and cause compartment syndrome. And you may need to do a fasciotomy and you can do those through an sclerotomy wound. But in electrical injury, sometimes you may need to go directly to a fasciotomy because of the nature of uh electrical burns. So let's focus on the wound care. Um You can see the original picture that I showed you earlier of the, the young lady with burns from a scald injury, which um has got lots of blisters. Now actually to assess the burn fully and completely and to really get a sense of what size of the burn there is and also the depth you need to remove all those blisters. And you can see this lady actually had a general anesthetic um to clean these because we felt that was the most um appropriate for her because she was in extreme pain. But if that's not available, then giving opiate analgesia as much as you can giving gas and air, um as much as you can um to allow you to clean and assess the burn wound. Now, we assess this as a in this particular patient. Actually, 33% of her body was burnt and it was all superficial partial thickness. And so we carried on dressing it. And the principles of all burns dressings are you need a non aerin layer, which is easy to remove off the surface of the skin. You need an absorbent layer because the there'll be a lot of fluid coming off the burn and then you need something to secure it. My basic recommendation is paraffin soaked gauze. So, Vaseline gauze. So we use something called Ginette, which um is something that is relatively available and is cheap. And um you put that on as the first layer and then you put a gauze or Gangjee or wool on a cotton wool on top of that to absorb any fluid and then um c create bandages um are simple things to put on. Now, um, in an ideal world, you try and minimize the number of dressing changes. But if some burns in certain situations burns ooze a lot of fluid and then you may need to change them regularly because if they're oozing all the way through, then they're a higher risk of infection. And so, um rather than having thicker and thicker bandages, it's better to actually change the dressing entirely. Now, in certain situations, you may keep the gel int intact, change the gauze or the wool, cotton wool and the crepe bandage and then reapply. But after a couple of days, I think it's important to change the dressing if only to look to see whether the burn has become deeper or not and whether your plan to continue with dressings is appropriate or not. Um So even if you've got a deep burn that you might consider surgery for, you're gonna put a dressing on it and those principles that we've talked about, uh, are important. The next thing is once you've started giving them fluids, you then need to start feeding people and the quicker you can feed them the better. Now with a large burn over 20% in adults and 15% in Children. Ideally, you need to use nasogastric feeding. In certain instances. Jugal feeding is even better because, um, that seems to avoid the problems with um, regurgitation. And also, um, you can continue feeding um during anesthetics. Um If you do not have nasal gastric feeding, then oral food is absolutely vital. And the quicker you can start it, the better and high protein, high calorie food is essential and you know, whatever is available is really good. Some, some hospitals will have proper supplements that you can get in others. Just food, milk, eggs, meat, beans, rice, anything. But ideally looking at 50% of that being carbohydrate, 30% being protein and 20% being fat. And you will know if a patient is getting well fed because their weight won't go down. Um, you've got to also take on board the fact that they will have been given a lot of fluid. So that may affect their weight initially. But if they continue to lose weight, it means that they're not getting enough nutrition and that means they're less likely to heal well. And it also means it will take them longer to recover and get back to normal activity. So starting their feeding on admission, um nasogastric if, if it's a large burn and making sure that you regularly monitor um through weight and also checking their albumin levels. If at all possible. Now, if their albumin is low, you don't need to give them albumin, you need to give them food. And that's the really important thing. Albumin is a, is a measure of, of how well they are nourished. The other thing that's important is to keep patients as mobile as they possibly can. And so in my unit, I get everyone to try and sit out as much as possible. Even if they're ventilated, we try and sit them up, we try and get them moving and we try and keep them as unsedated as possible to allow them to, to spontaneously move. And that's really important because the more they can, um, move and the more strength they have, the better they'll use the nutrition that they're given, but the quicker they will also heal and the quicker, um, they will be able to get out of hospital. And it's important. We do stretches and, um, um, splinting. Um, so stretches in theater when, if they need to have surgery and it's part of my routine. So they, you know, they try every patient on our, on our ward tries to sit out. Um, everyone has to go for a walk and we do the best that we can in the circumstances that they've got. But the other thing is especially with hands and shoulders and elbows. They need to have anti contracture positioning and the best way to do that is splint. Now, you can either use what we've got, which are thermoplastic splints which are shaped specially or to use plaster, um, or whatever materials you have available. And I think the important thing is, um, making sure the patient is, um, positioned at all times in a safe functional position. Ok. So with the deep dermal burns, uh they need surgery and um, the principle of any surgery is to excise the um, the burn down to healthy tissue. Now, traditionally, people used to say, well, I'm going to excise it until I get healthy bleeding. But that often meant that patients bled an awful lot. So as much as possible, I infiltrate any burn wound that I'm gonna excise with weak adrenaline solution. So, uh I normally use two mg of adrenaline per liter of fluid and then I will inject it into that tissue and I'll try and get it as tumescent as possible so that we don't lose blood. Um, and that's really important. Now, you can see in the upper picture that's a picture of me debriding a burn wound with a guarded uh knife that's called a Watson knife. And you can see the tissue underneath is golden, healthy looking fat. If it doesn't look like that, then it's not deep enough and then you need to take some more. And so don't look at the bleeding because you've got lots of adrenaline in it. Look at the quality of the tissue remaining. And, um, that once you've got to non bruised, healthy looking tissue, you can stop. Now, um, that's ok. But if you've got a very deep plan or you're worried about, um, um, significant blood loss, you can do something called fascia excision. And that's the picture on the right where, what I've literally done is I've cut right down to the fascia and literally ripped off all of that tissue, pulled it right off. Um So it is it OK if I interrupt you to ask a few questions from the chat, the first question um is by Ali and it's, is it proper to intubate the patient if they present with a facial burn even if they don't show signs of airway obstruction? Um No, that's actually quite dangerous. So, um so the practice that we have certainly in our unit and I think in quite a lot of units now is only intubate them if you really have to. Because if you intubate people, for what in inverted commas called safety, um they can get problems from doing that themselves. So there's a much higher risk of getting um chest infections, pneumothorax, um and also um the generalized increased risk of sepsis because often they have extra lines put in. So my advice is do not intubate people unless you can really justify the need to intubate them because their risk, the risk is higher if you don't. Brilliant. And there's another question as well. Um There's quite a few. Um, do we need to give low molecular weight heparin to avoid DVT? Um, yes, I think in most places now we do give low molecular weight heparin. Um, the actual, um, risk of DVT in burns is difficult to quantify. Um, but I think the risks of DVT outweigh the potential complications associated with giving um DVT prophylaxis. So certainly in our unit, we give it and we give it from day one. Brilliant and someone else has asked, they said, I'm aware of the traditional Parkland formula being four mL times T BSA times WT in um like weight in kilograms and not two mL as mentioned in your slide. Yeah, so there's a bit of change in the way that people are doing things. I think a lot of people have recognized that four mil per kilo per percentage burn, which is sort of like the upper end of what people used to give. It was between two and four. And our standard unit used to be our approach used to be four mils per kilo, but um often patients had more fluid than they needed. And so in, in again, my practice is you start giving people fluid according to two mils per kilo per hour. And then to some extent, you can forget about the formula altogether for the and what you should do is just look at their BP, pulse and urine output and change the fluids accordingly. So, yeah, Parkland really is a starting point. Not a, you have to absolutely follow it because if you try to follow it, you won't be treating the patient, you'll be treating a number and it's far better to focus on how the patient reacts to the fluid that you're giving them and avoid giving them too much fluid. Brilliant. And there's another question as well as a few coming up. Um, do you do a closed wound dressing for all form of burns? Yes. So the only time that we wouldn't, may be for facial burns where we will, um, apply, sometimes we'll actually apply a dressing to the face sometimes if it's relatively small, um, we'll put, uh, Vaseline or paraffin oil on the face. So that's still addressing, it's just that it's not a big bandage. Um, um, some, sometimes you can try and expose wounds and, um, in places where it's much hotter, um, I think that's probably acceptable but it does take longer for burn wounds to heal. And if it's oozing a lot, you need to try and encourage it to crust up as quickly as possible. But I don't really have that much experience and I think the general approach for most people now would be to dress it. Um, with the exception being the face. And another question is, what do you think about antibiotic, prophylaxis of local burns and what is the best way to clean a burn? So, um, antibiotic, prophylaxis, I don't think there is a role for it. Um I think you should only use antibiotics if you've got a clear indication for treating an infection and sometimes that's difficult and I was going to come to that later on in my talk. Um But all you do is you increase the risk of multi resistant bacteria. Now, we treat people from all around the world and there are some places where they have a very low threshold for giving lots of antibiotics. And all we find is that these patients turn up with highly resistant bacteria which are difficult to treat when they do become unwell and it just increases their risk of death, cleaning wounds. So, cleaning wounds, we use, we use water soap and water. So, um, so we'll use a weak iodine solution um with some water. Um, it doesn't have to be well in the UK, the water is pretty clean. So we just use tap water if need be, we can shower the patients. Um But if, if you're not, if you're not confident of the the water supply, then weak iodine solution is a good cleaning solution. And another question is is the administration of omeprazole to prevent burn ulcer applicable. Um Yes and no, in the, the most important thing is to feed people. If you feed them, they're less likely to have, um, burn ulcers. Um, we tend to give omeprazole or something similar. Um, if, for whatever reason they can't eat, uh, or they're not absorbing their food. Um, or if they're intensive care patients and they're ventilated. Um, but even then the food is more important than the omeprazole. Um, but yeah, ventilated patients, people who aren't absorbing their food or if we're giving significant amounts of nonsteroidals to help with their pain relief. And on to the next question, just let me know when you'd like to continue. And if you'd like to leave some of them at the end, why don't we do this question? And I'll continue and because I've not got too much more. So um someone else asks, why should we avoid giving normal saline? Uh because it's got a high uh amount of sodium in it. So it has about 100 and 50 millimoles of sodium. Um The plasma runs at about 100 and 35 to 100 and 40 if you're giving a large volume of saline. So maybe 10 liters of normal saline, you can make someone very hypernatremic and that can cause problems. So, so in, in our practice now, we very rarely use normal saline uh for that specific reason. Um Cool. OK. So um surgery we've talked about, you can shave what we call tangential excision or you can do a fascial excision to limit blood loss. The problem with the facial excision is that skin grafting onto the fascia does not give a good cosmetic or functional result. So, how do we do skin grafting? Well, first of all, um, the traditional method which you can see in the bottom left is using a skin graft knife and, um, you have to be reasonably skilled at taking it and you can take skin grafts from the same area two or three times and it will still heal if you don't take them too thick. Now, in the upper picture, you can see we're using an air powered dermatome, um which still takes a skin graft. And you can see that's what is the middle picture shows what a skin graft on the site looks like. Um, the white is the dermis of the skin and you can see um there's some bleeding. Um And we tend to address our skin graft donor sites with um uh something called CAL to sta which is an alate and try and leave it intact until it heals. So, um, once you've taken your skin to put on your uh wound, having debrided it to healthy tissue, we often mesh the skin and the meshing is really to do two things to allow any residual blood to come through so that you don't get any um hematoma developing between the skin graft and the wound and therefore reduce skin graft take. Um But also it helps conform to the wound. So it can go up and down and in and out if there's an uneven surface and also if you widely mesh and you can see the different types of meshing, you can get from the hardly any mesh to really wide mesh. Um If you've got limited areas that you can take a skin graft from, then wide mesh will cover a wide area. But it will also take a long time for the gaps to fill in from the skin and the wider a mesh, the more scarring you get and the more contraction you get. So whenever possible, use the minimum amount of mesh. Um, and that should especially be the case for the face and hands where we try and either um just use sheet graft with some holes in it or 1 to 1 mesh, which um is what you can see in the middle upper picture of the mesh patterns. The other, the next important thing is to secure the skin graft either with staples or with stitches and then use a non decent dressing with some absorption and securing. And most people will look at skin grafts between three and five days um to see if they've stuck and if they're beginning to incorporate into the tissues, if your skin grafting around the joint. And you can see in this picture it's near the ankle joint, then I would actually splint the patient. So I'd um have a plaster to stop the joint from moving. And if need be, have them on crutches. If it's around the ankle or the foot or the k, uh, if they, if it's around the knee, then I would stop them from bending the knee. If it's on the hand, then I would, uh, put a, a plaster to stop them from bending their fingers or hands. Um, just a few special circumstances with chemical burns. Just remember that, um, they need lots of good early washing and the quicker you can wash them, the better it will be. But if they've caused enough problem to cause skin necrosis or they've discolored the skin, then they almost certainly need to be skin grafted. So if they, um, the hand burn is an acid burn and that needs to be skin grafted. Um, on the face, when you dealt with a caustic soda or alkali burn, you can see you need to do quite a lot of skin grafting around the face. And that can be quite challenging. But more importantly is make sure that the eyes are ok because alkali burns to the eyes can be absolutely devastating and can cause blindness or permanent corneal damage. The other thing to note though is that in, sadly, um, very many people get assaulted with acid and it can be a very traumatic experience for them. And I think it's understanding that, that they need to be in a safe place and sometimes almost always the person that has assaulted them, um, is known to them and it's our duty to make sure they're protected and they get not only, um, protection from whoever's assaulted them, um, but also to get the appropriate psychological support and potentially a means of getting away from what may be a very abusive relationship. Now, it's very difficult, but I think it's important that we do that and, um, there are charities out there, um, which will help and it's really important that we highlight that um electrical injuries, we've already talked about it. Um The commonest uh complex electrical injuries tend to be with high voltage electricity and there are two or three things, one, there are a much higher risk of getting compartment syndrome. Um So it's important to test that. So looking to feel the muscles of the limbs and if they've got pain on muscle movement, then you need to be thinking if they got compartment syndrome because if they um have uh significant muscle breakdown that can cause uh hemochromatosis and that can cause kidney failure. Uh someone with a large amount of um muscle breakdown and myoglobinuria and kidney failure, uh much higher risk of death. So the skin injury may not be so apparent, but the muscle injury may be significant. Um in terms of the cardiac, um my general approach is if the ECG is normal, then you do not need to monitor them for 24 hours. Um If the ECG is not normal, then it's important that you do monitor them and make sure that they're, um, closely observed. The other thing about electrical injuries is that people say once you've debrided an electrical injury and you can see a really severe electrical injury up at the top. Once you get rid of all of that, you go back two days later and there's even more dead skin or tissue or muscle or bone. And if that is the case, um, it's not the fact that it's progressed, but rather, um it takes a while for the injured tissue to fully declare itself so often with severe electrical injuries, it's important to debride but not necessarily reconstruct the first time, but to go back a couple of days later and maybe a couple of days after that to make sure that you haven't got any further necrotic tissue. But um again, the example at the upper part of the screen um shows you that sometimes you have to consider amputation as a safe way of avoiding kidney failure of muscle problems and significant wound infection because of all the dead necrotic tissue that's there. So consideration of early amputation is important. Um infection is sadly very common in large burns, but it's not just the burn wound itself, it can be chest infection if they're ventilated or if they're not moving very much. Um lines are a very common cause of sepsis. And so when someone becomes unwell and they've had a central line, for instance, for a few days consider removing the central line, um, because that may be the cause of the sepsis. And then again, the burn. And you can see a picture, the picture on your right shows a person that had completely intact, well taken skin graft three days beforehand. And when we looked at it, um, um three days later, you, we saw this and this is typical of a staph aureus infection. And what this guy needed was flu cloxacillin specifically for his staph aureus infection, daily dressings. And er, and then thankfully, we caught it early enough and he was able to heal with just dressings. The picture to your uh in the center on is a thigh which shows thrombo blood vessels blackened skin. And this lady died within a few hours of this picture being taken because she had invasive pseudomonas infection and she had a significant amount of um aggressive invasive pseudomonas. So often pseudomonas gives you a green tinge to your dressings and it's often because it's quite wet. So you try and dry things out by either leaving it to the air for a little while, um, or have very absorbent dressings. Um This lady was unfortunate to get invasive pseudomonas and we took her to theater immediately, but she had overwhelming sepsis which was very difficult to treat and she passed away. So, the important thing is um identify if someone needs antibiotics but don't give antibiotics unnecessarily because if you, when you do get a problem. Um, if they're got resistant bacteria, your antibiotics will be a waste of time. But also wound management, daily dressings can help decolonize a burn wound if it's looking like it's, um, a bit smelly. If it's oozing a lot, if it's becoming increasingly painful, then change the dressings more frequently to reduce the chances of it getting infected. Yeah. Um, final couple of slides. Um, sometimes patients have such a severe injury that they are not gonna survive. Um in the best burn centers in the world, someone with a 90% burn um has a 50% chance of surviving um in much of uh resource poor uh hospitals. Um if someone has a 40% burn, they have a 50% chance of surviving. And so it's important to understand that that's a risk and to be realistic about what's possible with the resources that you have available to you and to make that decision with senior colleagues and to involve the family early on very occasionally, someone will become very unwell after you've all after you've treated them and they've all been doing well, but they may get a late infection. And if that's the case again, you may have to consider whether they've got the ability to survive what may be a very severe septic episode. Um Final thing um this is a picture of Archibald Makindo um who was famous for treating burns patients in the Second World War, but also for providing a lot of psychological support to his patients. And I think that's important for us because many of our patients will be scared, anxious and have gone through a very traumatic experience. And it's important for us to treat them with kindness and with support and to listen to them when they tell you that they're struggling and they will often express their anxiety sometimes as if it's anger and it's important for us not to react to that. But rather to understand where they're coming from and to provide them with the kind of psychological support they need to be able to get through what is sometimes a significantly life changing event, but it takes time and they will not change. So sometimes simply saying, oh, you'll get through it, you'll be fine is not as important as how can we help to make things better. So, um that's the end of my talk. Um Sorry for going slightly longer um than planned, but I'm more than happy to answer any questions that you have. Uh I know we've answered some. Um But if there's any more that you'd like to ask, please, uh go ahead, Ria will fire at me. Yeah, absolutely. Um Brilliant talk. Um I, I found it so interesting, I think as a medical student just to see um so much of the kind of how you treat burns because I don't think we get taught a lot. Um So I'll go on to the first question says, is there any advantage of not deroofed the blisters covering after draining the serous fluid? Um, some people do consider that. I think there are two advantages with a large burn. I think it's just going to accumulate and often you get, um, fluid just building up and it becomes a gooey mess. So it's not so good with very small burns. Yeah, maybe one or 2% you could consider doing that. But for larger burns, I think it's better to remove it. But also by removing the blister area, you can be sure that you've got the depth of the burn, right. There's no point in guessing that it's a superficial partial thickness burn. It's better to prove it because the difference between a superficial partial thickness burn and a deep dung burn is basically whether you're gonna skin graft it or not. And if um you are gonna skin graft it, the quicker you do it the better. Um I think I saw a question about how much fluid can you give? Um just as much as you have to give to be able to um get an adequate urine output. So that is, it's not that there's a 50% limit, but, but it depends more on how much fluid you can give and whether it's having an effect. So sometimes patients will go into renal failure and then you need to make a decision about whether um if you've got the facilities to put them on renal support. So put them on hemodialysis. Um, and if you don't have those facilities, then actually, is this gonna be a survivable injury? So there isn't a limit on the amount of fluid, but you need to also know that there's some, um, you know, you've gotta get some positive reaction from your fluid management. Someone's also asked how can we choose between the open and closed dressing method? Um, don't choose, just go for the closed if you can. That would be my answer. So, um, certainly some people are experience in managing things with what we call the, the, yeah, the open method and to dry the burn as much as possible. But, but generally, I think it's better unless, um, dressings are difficult to get a hold of or, um, there are significant issues with, um, very wet wounds and pseudomonas colonization. It's better to leave things dressed rather than open. Um, but it really does depend on your local practice and some people will be very experienced at managing patients with the open method and that's fine. But you also have to accept that it may take a long time to heal and then it's, but it's also important to before you decide that whether that is a patient who's gonna have a burn that's gonna heal by itself or whether they need to be skin grafted. Um So, yeah, it's a difficult question in my practice in Cold England. It's better to address it than to keep it open. And another question is so someone says regarding margin ulcers, is it common that we have to think about it often? Um If you margarines, ulcers basically are squamous cell carcinomas from unhealed wounds, often 10, 2030 years after a particular injury. So the point of that is if you get a burn wound healed quickly, they're less likely to have problems with breakdown and ulceration later on down the line. Um, even a year down the line. If it's not healed, then I think you should make an effort to get it healed if at all possible. But if someone comes to you and says this ulcer I've had for 30 years and it's getting bigger, then pretty much you've got to assume it is a squamous cell carcinoma or a Marlins ulcer and then you need to excise it, uh, and send it off for histopathology to confirm that. Um But yeah, I would hope that you can avoid it by good wound care right at the beginning. And another question is if we de roof blisters, don't we expose the wound to infection? You already have because they've blistered, it's gonna fall off anyway. So the important thing is that you put a dressing on it, um, once you've given it a good clean, so you've lost the integrity of the skin the moment it blistered and that blister will burst, you won't be able to preserve it and if you aspirate it, it will shear off and you're still gonna have problems. So, yeah, uh people get very um um it's almost like a philosophical thing about blisters, but I think you need to take a simple, straightforward approach and do that rather than um get too worried about it or not. But yeah, people always argue about whether you keep it or not. My principle is take it off, look at the burn wound, see what you're looking at. And then you can also see whether it's healing or not. And another question is uh someone's asking if you can briefly go over pain control. Um Wow. Um So the simple fact of the matter is burns are painful. Um The quicker you can cover a burn, the less painful it will be. So we talked about first aid and then putting cling film on before you put a definitive dressing on. So get the patient dressed as quickly as possible. The other thing is um reduce their anxiety by supporting them, talking to them trying to keep them calm. But yes, you need to give them pain relief and people talk about the analgesic ladder, paracetamol and ibuprofen and then maybe some codeine. Um and then maybe some morphine or Oramorph oral morphine. Um But if someone's screaming in pain, why not just give them morphine, just give it to them either intravenously uh or orally uh and just titrate it until they're not in pain, uh adjuncts to giving them regular morphine, uh paracetamol and ibuprofen or nonsteroidals. And then if they're still having problems, some people might consider giving them gabapentin, which is an antiepileptic, which is used for complex pain. But generally, I think most pain is ly controlled with opiates. So, uh codeine or uh morphine or oral morphine or similar variations. Um and you need to do that as often as you need to rather than hold back because if you've got a pain free patient, they will mobilize and they will eat, which is what you need them to do. And on to the next question, someone's asking if you could go over the different types of burns dressings again, particularly in low resource settings. So, yeah, I mean, paraffin, Gauls Ginette is probably the simplest one in places where it's very hot and humid. Um I mean, Philippines is a good example um where it's hot and humid, they just use gauze um to absorb it because that doesn't stick because it's so humid that everything's wet. Um There are other sorts of dressings that you can use. Um um But any kind of any kind of greasy gauze um as the contact layer is useful as you get to other places, people have used something called Telfer which looks like bread wrap. It's literally a clear plastic with holes in it. Um Or people have used um um similar ones such as meel, which is quite an expensive silicone dressing. Um, but I think, I think really the commonest easiest access is paraffin gauze, Ginette or Vaseline covered gauze. And if you can't get that, then put Vaseline on the wound and then put some gauze on top of that. And the next question, how often do we need to worry about stress ulcers if you feed them well, if you feed people regularly and quickly, the likelihood of getting a stress ulcer is very low. Um, I've been a consultant for 20 years and I've been doing burns for about 30 years and I think the last stress ulcer we're aware of in a non alcoholic, um, was about 28 years ago. So we don't see them very often because we feed them early and yes, we do give them omeprazole, uh, or similar antacid type stuff. Um, people who drink a lot of alcohol are much higher risk of gastric bleeds because of their alcohol and their varices. Um, but even then feeding them early is very important. And yeah, we don't have problems with, with stress ulcers, burns, ulcers with that regime. Another question is, how long do we wait until we decide to skin graft? Um, ideally, if you can look at the burn wound at about 48 hours, you'll have a good idea as to whether it's become deep or not. And as soon as possible after that, um, if you think it's a deep dermal or a full thickness graft, then I would get on and skin graft it as quickly as you can. Because the quicker you get rid of that deep burn, the quicker they can start healing. Now, if you're not sure because although I've shown you some pictures of a superficial particle thickness burn and a deep dermal burn and they look very different. Sometimes if you're just not sure or if there's a big mixture, the approach that you can take is keep, um, dressing it for two weeks. And if, uh if it's all healed by two weeks, great. But if it hasn't healed by two weeks, skin graft, everything that's not healed. So our general approach is if you're not sure, uh, and you don't want to do an operation, then wait for two weeks and then skin graft, whatever's left. Um Sometimes even I, even if you think you've got it right. You may have misdiagnosed a, a burn thought it was superficial partial thickness and it proved to be deep dermal. Well, you're gonna know that at two weeks. And so if you can, if you're sure it needs a skin graft two days, then do it at two days. If you're not sure, then dress it until two weeks and then skin graft, whatever's left to heal. Um, has said how effective a bread crumbs and burns treatment. I have to say I have no idea. I've never used them. I wouldn't recommend them. Um, so I can't make any comment beyond that. Um There's another question that says, is there any limit to the, I don't know if you answered this, but it's, is there any limit to the amount of fluid that can be given within 24 hours in burns resuscitation? Not really. You give what they need, but don't give them too much. So, as I said, it's dependent on their urine output, their BP, um and their, their pulse. Now, if you have a good intensive care unit, you may need to give them vasopressors. So, noradrenaline is what we would normally use to improve their cardiovascular output. And so if you're finding, you're using more and more fluid, then you need to ask yourself whether there's something else that you need to be doing. And another question is, what is the role of silver nitrate in burns? We're almost done. Yeah. So silver nitrate is a very good topical antiseptic. So it, if you feel that a burn wound is becoming smelly, it's got surface slough, it seems to have deteriorated or it's at risk of infection, then treating with silver nitrate is very useful because it will reduce the bacterial count. But I wouldn't use it all the time because it can also delay wound healing in a noninfected burn. So, so if a burn looks like it might get infected or we were worried about it getting infected. Uh You know, there's redness, there's tenderness, there's slough. Um then silver nitrate, very appropriate um as a good topical antiseptic. Um but don't use it um all the time um because it will delay wound healing. Brilliant. So that's all the questions that I can see that people have asked. There are quite a few there. I think people are really interested in the content of your talk. Um I'll just wrap up by saying for everyone in order to claim your attendance and get your attendance certificate, you need to fill in the feedback form that we've put in in the chart and on top of that as well, it will be emailed to you do message us if you don't get a copy of it and the recording of these slides. Um Would you like the recording to be made available? It? Yeah, I think that's ok. So the recording will be available in a few days time because we just edited, put it up, but I will upload the slides basically as soon as possible after this talk has ended. Thank you so much to everyone for attending. And please do attend the next medal education talks. You'll be able to see them if you click on the organization. Thank you, everyone. And I'll stop broadcasting here.