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Um as murder. So it's seen as that. So she shows some of the pictures and that is what made me want to do my elective. Um And why I did apply for this job, which is a plastic surgery retraining job. It was the only bit of plastics I ever had in med school was one torque which I went to electively. I don't think it's taught properly. Um So I'm hoping this is a bit of an introduction of something a bit different and gets your brains thinking cos I think Saint Georgia is quite unique in that they teach plastics very well and that you have a good couple of weeks with us. Um But ask questions, get involved. Safe space with the final scenario. This is gonna be the tough one cos it's all about everything coming together. So this is your scenario today. Brian says to a male who's been brought urgently to the burns unit, he sustained widespread flame burns when a gas cylinder exploded. Please assess and treat B Brian based on the injuries he sustained, say this is a trauma we've all been going through and adapting our at es are we worried about Brian. Yeah. So what do we wanna do? 88 we're seeing him as a trauma. We're going to do an ATL S trauma. So we're going to adapt that somewhat. Do we just start with the bones? No, we start with everything else. So, you are the sho for Ed, you're just in there. You're watching all this going on while, um, the trauma team are all assembled. They're going to be assessing Brian. You're with his wife and you're going to take a collateral history. So what do you wanna know about how Brian came to be in a 11 time? So this was about an hour ago, he was brought in by helicopter and hems. Ok, how it happened. So he was hosting a barbecue. He hadn't used his gas barbecue in a few years. Um on light of the barbecue, he spelt a bit of gas. Um He thought this was a bit odd. So we tried to remove the cylinder and move it away from the house where he brought it towards the shed and it exploded. And how big was the explosion? And how much was, was he pushed away? Was he injured by any other partners? Did he see anything else? So he wasn't, there wasn't a blast. It was just the shed caught fire. He had a small, he's got flash injuries to his arms and to his face and to his torso. He's the only person injured in the incident witnessed by his wife and his Children. Was he responding after the fire or was, or was he unconscious? So after the fight, his wife, um, sprayed him with water and he was just kind of rolling on the floor trying to put out the flame there. He caught onto his clothes. All. How long was he on the fire? For seconds. His wife, luckily it was a hot day in the summer. So he got the, has had the hose on him till the paramedics arrived. Does he have any other? I doing? No, it's for, well, does it hurt? He's screaming, but we don't know if that's a shock. Does you know his blood type? Uh, no. Does he want to? No. What's his g, um, they're doing the assessment at the moment and his wife's obviously just with you just trying to, is there anything else you need to know any medication at the moment? No, it's, well, um, arms face and front of his chest. Anything else? So, yep, you picked apart all the kind of things I'd want to know from a collateral history from his wife. So, kind of what happened. What type of burn is always very important. And then the next thing to move on to is like, what do they do to first they've manage the work burn. So, you'll see, especially in acid attacks in London, pouring the water on. We need to know how of how long they were cooled down. Was it just, they just sat there and let the burn continue where they left. Was it too dangerous for anyone to help for them? You need to know what first aid has been given. And so it's important to know that. So like if it's a child with a flash burn, they need to get in the shower. You want to know if you want to be in the shower for at least 20 minutes. I don't know if you've heard just cool, not cold water, room temperature water over the burns and then dressings. So you'll see people with um, cling film over the burns, genuine dressing, um G soap gauze, but the main thing is obviously things can get adhered to the burns, don't remove those there and then because that could be extremely painful. You've got friable skin now and what analgesia because burns are painful, which we picked on here, er, give them the analgesia and know what you've already given because you're gonna need some strong stuff. And this is why I was touching on what type of burn really hammering home? What they sustained? Was it just the explosion which we're mentioning over here? Was it just the blast injury or was it flame injury? So in Brian's case, it was a flame injury to his arms, chest and face, I've got some pictures up here. Can we pick apart what type of injuries these are stained? The different types of burns. Does anyone recognize any sunburn? Sunburn on the left? Yeah, I'm guessing the different degrees of burn. Oh. Is there hot water? Yeah. So the two of the kids, um, again, very common. But as I did my lecture at Charleston and Westminster, um, this one is a cup of tea forming down the front of a baby. Very common. Very sad. But it does heal the bottom. Right. Why am I worried about the bottom? Right? They are accidental. Exactly. That non accidental. Whenever a child, I wanna hammer that home in your, to your history with your exams coming up. Always ask about na I never miss out, especially in a pediatric case. Just shows your thinking of the bigger picture, but it burns like that. This is where even if an, an elderly person have been put into your hot bath, you can also have, um, kids where they'll have almost a pair of socks of the burn where they've had their feet put in, they're the kind of things that should be red flags in your mind. Um, on this gentleman here, this is a friction burn. So this is where he's been in an accident and a piece of rope has gone over his skin and torn that. So that's why. And again, you were saying, I think we would say different degrees of burns. These are all actually quite superficial. So the main thing here is you've got to look at different colors of skin. And it's really important to look for the factors because it doesn't matter how much melanin you have in your skin, you can understand whether it's bleeding or not, whether it's got a capillary refill. Especially when I was on plastics a couple of months ago in a referral. I want to hear exactly how that skin is looking. Pictures are so helpful no matter what. So this you can see there's bleeding, it's white and pearly, which is worrying me that it's deeper, but you can assess this as per normal burn. The cartoon picture is black. It's a different type of burn. Maybe not when you're categorizing in your head as a burn, chemical burn could be electrics, cos it's gone through the digits. This one is actually trying to show frostbite as well in the toes. Um, but again, electricity does go through so it could be in that one as well where it's, he's, you grabbed a cable and it's discharged through all your peripheries. And that's where you've got these discharging currents for your toes and for your fingers. And that's why you get the ischemia. The one on the top, right is quite hard. If I was to say you're on ent you've got someone with a positive lymph node in their neck radiation. It's a radiation burn. Exactly that, um, really complex in these types of patients because it's just cos of management. So, always think of the bigger picture. I've got a kind of a breakdown of like the five different ways you've got burns, always consider them because your management will change. Um, like if it's an alkaloid burn, you're gonna have to keep using water, it's not really gonna change. It's gonna keep burning if it is a powder. What do you do? Do? You just put water straight on it in Florida? Yeah, you laugh, you brush off what you can obviously not with your hands but whatever you can remove safely and then before you put water on them, um is the best way to kind of get it, especially in London. Unfortunately, different types of things are happening in the workforce and unfortunately with some other things, criminal events that you've got to be prepared for different things, being on different people and protecting yourself first, always wear the right PPA before you look after your patient and advisor gown glove visors always protect your eyes. So we start off with an assessment. This is again breaking down the different types of burns. Um the pitch on the right helps we're much more of a pitch person. So about period refills, what you can see whether it's blanching if it's coming back really quick branching. So your cat refill could be less than a second. That is usually official, deeper, less delayed, full thickness is completely absent. Painless is also the one you can remember. Esar heard that term before. So Esr is where it's a really full thickness burn, it's thick dead tissue. That is what you're looking for. It's leathery. You'll hear that word used around. That's what you're looking for. The middle is partial thickness. You're superficial and deep. Again, think of your layers of the skin. You've got your hypodermis, epidermis, dermal layer and the new subdermal subcutaneous flap. You've got to think of what you're involving and what structures are in there and that is why superficially it's inflamed. That's why it gets quick cap refill. As you go down, you've got your perforator start to be damaged and when you're all the way through, it's all the way gone. So that's why you get these presentations. But this is just something you have to learn based on that. This is just another again, explaining what I've already said what your kind of presentations are. It's a classic M CQ question usually for final year. Yeah. So in Brian, you'll help him with the burns assessment. As I said, he's got um full thickness burns and partial steep, partial thickness burns to both of his anterior forearms and arms to his chest, his neck and his face. He's got some superficial burns to his abdomen anteriorly. What is his percentage? I know no, the rule of nines is one way of doing it. Does anyone else know how you can also assess burns percentage? No. Yes. OK. You're all a lot younger than me. What, what is an easy way. What do you all have an app? There's genuinely an app where you can shade in someone's body. Um, or you use the patient's own palm and that represents 1%. So if you use that against that, then you can use that. Do we count all of the burns? I mentioned cos I mentioned he's got some full thickness, some partial, some superficial. No, no, not the superficial. It is only deep, partial and full thickness that counts your burns percentages. And that's why it's really important when we're referring to a burn center because it's your criteria for a referral or whether it's just vice if it is and you have to be very specific on your what you're assessing as your percentage. Cos for example, like when I was on plastics not too long ago, they referred us said, oh, it's a 10% burn. She bless her had had carbon monoxide exposure as well. So she was very pink and actually when I went and found all her full thickness burns, it was less than half a percent and it was actually they just couldn't compute cos they weren't used to seeing these kind of skin presentations. So when it was bright pink, thinking this is all superficial and there were a few areas of necrosis on her top of theirs, that was actually all that counted towards her burns assessment and it was her pink skin was just cos she was carbon monoxide intoxicated. So it was actually no, it was all just all, just tiny. It was all superficial or nothing at all because we, her skin was actually b blanching. It was fine. It was just discolored due to her um carbon oxide. But the actual, the only bits were like the tips of her ears where it was necrotic, that thick leathery tissue um where you just, you don't get any capillary foot. It's the best way, especially when they're intubated to assess is cap foot. So, yeah, also interesting, um, is that you've got to think of the age of the patient because Wallace's rule of nines is good for adults, but think the baby, their head is so much proportionally bigger than ours is. So you've got to assess based on that, especially when you've got these non accidentals. It may only be any. Ok. I wouldn't use that, but you'd be surprised how much is actually done in a child compared to in a dog. Yeah, these are the kind of ways you assess it. This is the better way. Er, this is the one that is used for these apps where you actually just shade it in. Um, it's slightly different to the rules of nine, not as easy to remember, but in A&E definitely use your rule of nines with the patient's palm. But when you're doing a specific referral, I would use this and have a clear chart. So do draw a diagram in the patient's chart. If you've got paper notes to really assess what you've got, as I say, plastics, it's pictures, information is power. So if I was to say Brian has, um, what should I give him? Eight, well, 11% bound to his body. Um, he, on his age reassessment, his airway is patent, but he's got a bit of a hoarse voice. He's breathing fine. He's got a rest rate of 15 sats are about 82%. Um, you've given high flow oxygen circulation, his blood pressure's 100 90 systolic rounding around that and his blood, er his heart rate is 100 and 20. What do we wanna give him? We do, but that's the next slide at the moment. Focal circulation. How much, um it's your appointment? Well, beca he has a lot of concerns. He's losing a lot of temperature and water. So you want to have a replacement uh, 0.5 per kg per um, that's normal maintenance. We have got someone with 11% burns. Is that like it is? So it traditionally was called the Parkman's formula. It's four, but this has actually been replaced. So as per the updated ATL S guidelines in thermal injury, you do two mills per kilogram. So you want two mil two times the patient's weight in kilograms times by their percentage of burns as done by that is how much fluid you should be giving them in 24 hours. You give half of this volume in the first eight hours. And then the rest of that in the next 16, you must catheterize these patients. You must, must, must because the only way to know about end organ damage is to be monitoring their fluid output. These patients should be on a strict, strict fluid balance assessment. In a child, you give three and electrical, you give four times the weight times by the percentage. Also the other caveat to that is in pediatric patients with those who are very sick, you may have to give this on top of their normal maintenance. So this could be a lot of math if they gave you that question. Yes, if someone has like heart failure, like a good going heart failure and they're prone to retaining good question. Um I would still be monitoring that heart rate. You're probably going to have a low, you do an echo, you'd be monitoring them. You'd have A&E there'd be an itu patient, whatever because they'd be on a burns ait U and there'd be a balance. But at the end of the day when you have burns, it's not just the fluid you're losing, it's that you also get rhabdomyolysis. And so maintaining your kidney function is comparative for multiple things, your lactate is gonna go up all these other things. Um A bit of fluid overload can be managed. Um But yeah, interesting question. So we touched on this and well done for picking this up. What did I say that made Amy say I want to, I have got need to intubate. I said something in the A two E that put me on edge hoarseness of voice. Exactly that any changes, any soot in the airways, make sure you're looking at the back of the throat, singing of the nasal hairs. A new cough. They've got a certain sputum, anything like that in a bit early Cos as soon as you get your laryngeal edema, you can't get the tube down and that's why it's really, really important. Um, you could consider bronchoscopy, but the main thing is maintaining your airway, you've got to always stick back to your aery of what is gonna kill them first. Um, so yeah, breathing, um, they may develop odds. Er, cos it's a significant trauma in the body so they go to be an itu patient, whatever. Um I've done the explanation here of why they get odds. Um, you can get inhaled smoke injury which just causes inflammations in the lungs. You've got this widespread inflammation in your alveoli and that's why you lose your barrier and that's why you end up getting acute respiratory distress syndrome. The main thing as well that worries me in um, Brian is that he has got burns to the anterior of his chest. Now, if Brian had burns all the way around his chest, their full thickness, they're leathery. What can't he do? Cos he can't expand his chest. So how are you gonna do that? Where do we cut him where the picture is? Yeah, you've cheated. We'll go to this side, which is escharotomy, which is dividing it. So this is where you've got circumferential burns around a limb cos that could lead to compartment syndrome around the chest and the abdomen. There's a good picture on the bottom, right? For the kind of thing you're looking for. If the tissue is not expanding, it's not gonna release and you're just gonna get a build up of black tape. I've done more explosions there. But the main thing is about just opening it up, freeing the tissues. Everything can be grafted down the line, all those dressings. The main thing is it's maintaining perfusion and you're not gonna get back to your chest wall does not move circulation. I've already touched on this. Oh, with the fluid replacement, you said Saline because I've taught you very well and a three, I always use Saline. However, in burns, the recommendation is for Hartman's just for electrolyte balance. So when you're doing your fluid resuscitation in a burns patient, Hartman's is your crystalloid of choice. Um If you're struggling for access, say Brian cos both of his antecubital fossa are burnt, IO is always a very good option. These are sick patients, a central line again would be a very wise thing to say. And then on the right as I've had at home enough catheterize catheterize, catheterize. It's the best and only way. So we look at disability. Um, if there's other things to consider more than that in a burns patient, they may, you may have in intubated them, they may have been intubated by hands before they even get you. There's things to always consider. So, what are the things you look at at disability? Mhm. Mhm. Uh, yeah. Bm. What's the other one? Ok. Four weeks from now, temperature we need to, we need to maintain the temperature. So they've lost the insulation of the skin. So in a burns theater it's hot as hell. It's very, very hot. You'll be sweating in there because they have it hotter just to maintain it. Um Lower G CS don't discount it as just they've had a head injury and Brian, he had a small blast injury. So never always prioritize that as per nice. But you have patients who have falls, they could be confused cos they've had carbon monoxide like my other case, they could be intoxicated and that's what led to them getting burnt because they can't remember the trauma and blood sugar can always come up in stress and in trauma. So disability also may have lots of extra things to manage there. Obviously, an exposure we've said we want to fully expose the patient while maintaining normothermia and dignity. This is the line that I use, but it's just an easy way to remember. It don't just rip off the clothes, as I've said already before, just cut around the adherent areas. Cuddle with cling film cos it helps lift with the evaporation. Analgesia veins, burns are very pa painful and you may need down the line. Your gabapentins and your other medications. In A&E morphine. IV is probably what I'd go to. They used to have a Kamin shower. I haven't seen that ever used. Um, I don't think it still exists but that was something traditionally they used. But IV morphine is the thing that I've seen in the past Tetanus. You've breached skin. Brian was outside. Always make sure you give them an extra boost and antibiotics. Again, you've got to think of your functions of the skin. It's more than just insulation. It is protecting you. It's a barrier to the outside world. So make sure you're covering them. These are patients who have the potential to get very septic very quickly. So, yeah. So Brian, you've managed him. We've got to the end of your A two E, we've given him all the things I've mentioned. Antibiotics. Tetanus. He's got painkillers, he's intubated. He's um, his wounds are dressed, there was no head injury of the CT. What are we gonna do with Brian? Where is Saint George's? Is a major trauma center? Some grabs, it's getting back to you. Oh, to you definitely. Is there anyone else we wanna call plastics? Would you wanna call me the plastics sho that of a month? Ago, the whole team will just bring them off here. So yeah, we've come, we've help with the assessment. Is there anyone specifically because anesthetics were at the trauma cor consult. So specialist burn specialist, we need to refer to a burn center. So, um I think these rules have changed. This is how often they change. So please please please check the guidelines cos I wrote this a year ago and I'm pretty sure it's now less percentages. So you will be, I would uh Brian, he's an intubated patient with a concern of airway injury who has got 11% full fitness burns. I would definitely be calling them not necessarily a referral but it's a discussion. Um I definitely think that'll take him cos he's got burns to the face and the hands and he's got an airway issue. There are just so many factors here, but the main things to think of are er, patients of a certain percentage in adults and Children. Please look them up if I'm wrong burns to certain areas. So, um I've, we had a burns referral, we had to send, who was a patient who had burnt their genitalia in their perineum and the back of their penis. And so they definitely need a specialist cap um circumferential burns, cos again, this is where I was saying about the risk of compartment assuming drugs, they need the eom any chemical electrical burns because these patients, it's not just the initial trauma, there's more that can go on down the line. Electrical burns, you can end up with um cardiac arrhythmias down the line. You can get rhabdomyolysis down the line. Chemical burns can keep going further. There may be further risk factors. Discussion is usually with patients who have got significant comorbidities with a small burn because they also have the risk for infection. And so that may need more specialist management. So more of a discussion than an absolute referral. But as I say, na I call them because they need the right people, the right support teams for these patients who have been a victim of this assault. But they're the main things. Any questions about burns. It's really interesting. If you ever get a chance to see a debridement, please go. I was very fascinated to I A student. So now you've got some questions and I've tried to do them on bits of plastics that I think you touch on a med school. Don't worry about these. I know plastics isn't taught. Your med school is unique, but we'll give it a go. OK. Number one, an intoxicated patient sustains for an outstretched hand, well done with pain in the middle of his palm. Pain increasing on dors affection and the AP film confirms Terry Thomas sign. Is it a third metacarpal fracture? A scaphoid an ulnar styloid fracture, radioulnar ligament sprain or a scapholunate association f increasing pain in dose flexion, flexion, dorsiflexion. OK. Good. I tell you. I know. Well, I mean, OK, we did talk about this. No, he said, would everyone like the X ray or was it the guy with the G in his face? It's the guy with the gap in his teeth. Exactly. That well done. So, a sprain tear, you've got to think of your radio on a ligament where it'd be, it wouldn't be in your palm. It'd be slightly more proximal on a styloid. As we mentioned, there's this little knot in here on your wrist. Shouldn't be having pain in the middle of your palm. Um, sw fracture base thumb. A SB always think of that third metacarpals around here. So it would be a bit higher up. It could be in the middle of your palm. But Terry Thomas sign is your clue here. Always is a scale for l association. Very unstable injury. Please see it quickly. Question two. A patient undergoes a total mastectomy and concurrent re reconstruction with a DP. What is AD E? Um OK. Is it where? Oh, that's what cause um, there was a lady who was having a mastectomy here and when I was on prostate and she was meant to, but unfortunately, didn't have uh well, I mean, I don't know if I should have um where they were going to remove the skin and some fat from her abdomen. Just the fat and no skin fat. Yeah. And a bit of hm. Yes. Specific blood vessels. So, so, you know, the one with the tummy tuck. Yeah, that's exactly it. That's, this is, this is, well, not a tummy tuck. It results in a tummy tuck. But this is how we have the flap, anyone, anyone seeing a dep I was meant to, but she, last minute, I wouldn't understand that we made. So, um, how do we feel about flaps and grafts? Any idea at all? About flaps and grafts? A little? OK. We'll start with question a split skin graft. What is that? That's, it's the not full fitness. So it's like you can use bigger areas. You can, you can take bigger areas and cover bigger areas. Yes. So the potato peeler is called a dermatome, which is like an electric thing. It borrows skin, let's say from your thigh, we can then make it, which is where you use basically something to break it up and make lots of fenestrations holes if you need to cover a larger area and then you stretch it. It borrows the superficial area and it integrates a little bit of the deeply bit skin, but it doesn't take the full layers. Hence why it's split thickness. Um, you dress that you just, that will heal. Usually the donor site is more painful where, where you donate, you've got a smaller site, you don't have to really split it up. So it's really stretched like a mesh. You can just do some cut fenestrations and you can use that. For example, if you're doing where you've removed a scalp lesion, that's still a splitz in graft. So you've got graft versus flaps, flaps where you rotate a larger bit of tissue. Well, a graft is usually a bit of skin. So a full thickness graft, for example, if you're doing like a nasal defect, you can borrow a little bit of skin four layers and then you stitch that on. It uses random vessels. Um just to get that local supply. Well, if you're getting a named vessel that becomes a flap flaps can be named in certain ways. I'm no expert in this, but there is which we use, you could do it based on what it is where it's come from. What's the fusion, um how you got it there. So you can have free flaps, which is where like the tummy tuck one where you just cut it out and then you put it into the defect for the mastectomy rotational where you can use a pedicle. So for example, a lap dorsi where you borrow the skin from back here to come round, they're the slightly different types of flaps usually have their names. We get back to the question. So we have three flaps cos it's definitely a flap. This is a mastectomy. She, we use a large amount of tissue. It's D is named because of its perforating vessel. So it's a deep inferior epigastric artery flap. So the D IE is in the dip perforator for pee. Then you get. So you've already excluded E cos we know the vessel and that is what if you ever go, you'll see the plastic surgeon spending ages, make sure they've got perfusion and microsurgery to help adhere that vessel to its, anchor it to its new place. It is safe. The answer. Rectus sparing. If it involves the rectus, it's called a slightly different flap. It's called a tram. They try not to use it. Cos obviously, they're trying to maintain the abdominal wall and help maintain that structure and you don't actually need it because it's more of glandular structure that you need. And that's why you need those superficial layers all the way getting down, cos you're gonna leave your base, you're gonna leave your pecs, but it just is more to help nutritionally structurally get that cos you can get some wasting. But anyway, that's the breakdown. Initially, of flaps and grafts are, we're a bit happier with that concept. Don't worry, I've only picked this up now. So don't worry. It is a lot and it's not taught. This is your question. Three. You've got an elderly patient who's been bitten by her cat. She de develops ascending lymphangitis which is like cellulitis, going up the arm in the lines of the lymph nodes with purulent discharge. What organism is typically cultured in M CS? So it's a cat. Cat bites any clues. Seven, you have a cat. Lovely. Ok. Do we know any answers? It's not why cos it's just on our skin anyway. So we're down to three. Anyone heard of any of the others? Please? Let's go. Testosterone. The cat scratch disease. It's not cat scratch. It is cat bite. So it's more one than you, but it is a weird one. the answer is, you know what's wrong. B um A yes, it's on our skin. It's also somewhere else. It's in our mouth. So it's most commonly from a human bite. So a bite bite. So if you ever see someone get punched in the mouth but they say, oh, they just fell. Staph is usually grown in there. Um, er, C and E or your skin commences. D anyone heard of this one? It's from a rat bite again. It's just these weird ones I remember for mine, I had to learn all these weird parasites that give you diarrhea and weird bacteria from different animals. Like there's the one where the rats wean something and you drink it. I remember learning that from my finals. It comes up though. Genuinely. It always is the way these weird ones come up but they find a way to remember. But pasteurella is the one that comes up in cats. It's just that weird one. It's very common in them. Now, you remember think of cats like milk pasteurella. All right. Next question. You've got a child who's stayed a two centimeter eyebrow laceration. It's a clean wound with opposable edges. It requires closure to the superficial skin with sutures. What suture would you use? Ok. Cine see. Ok. We have ac we have anyone else ba C ba DD. Anyone else where you were gonna go through the whole alphabet? Hey, fine. Ok. I wanna ask a sub question. Which of these are absorbable, which are not absorbable? Oh, all right. Come on. Isn't a nylon is absorbable. So, nylon silk and proline are not absorbable. Monocryl and vicryl repeat and vicryl are absorbable. Monocryl is better for your subcuticular. Vicryl is better for your simple on the face. Actually, we sutured with this, that one I've just remembered that we used this exact suture on a 10 year old child different. There we go. Um, sizes of sutures is one silk big or small. It's massive, is nine nylon big, very small. So they started off making them two was the biggest one and then zero and they didn't think they could get any smaller. And then they did. So it goes 1201 O2 0304050607080 no, no. Which is where we land. This is a child's face. Where do we use kind of 12 kind of sutures, big laceration, no abdomen closure. Um, I use 21 bit crawl sometimes when I'm helping out with the hips. So the tens for facial after closure. So the big muscles. So one silk definitely isn't uh too big Turo in a child. Again, I have to say it's too big. I would be using a three or four in an adult skin in a child and on their face, I want it small. I want it pretty because I was on plastic for six months. I'd go for six OVP because it's absorbable nino nylon we used for N digital Nerve repairs. Someone must have seen me. I left a poor med student out when I was trying to do that. It is pretty hard. And really you have to use micro scissors and sets and we definitely wouldn't need that. Nine is way too small. 65 in a slightly bigger child is right for the face. But I think when you're doing nice hip stitches to the skin, I'd go for a 60 back to a PED or if I was doing sub particular A 50 Monopril, which is what I used that day. I used a 50 Monory for D and a 60 for the skin. It's just to make it pretty and to have nice things. This is a little diagram to help if you wanna take a picture for where you're kind of going for where areas of the body, what size it is just for skin, not for deep. Um And about the kind of time you want to remove them. If this was an adult with an eyebrow laceration and I was worried about infection. I would definitely do non absorbables any time you're worried about infection. Do nonabsorbable cos worst case scenario you could take them out in between. It can let out the pus in a child. Taking out sutures is scary. It's near their face. They've already had to go through the trauma of the stitches. Maybe they've had to have G A let them dissolve. And that is that one? Any questions about sutures? So what if this was, are all of these only come in these sizes? No, so they all come in all sizes. So not all of them, but yes, they come in a good variety. So if you had a choice between 609 and 605, it would make any difference. It's choice. Um What in this question is it about? So in this question, they wouldn't, they wouldn't give you two options of 60 mole and 605 repeat because that would be very unfair. The m this question mainly is about size. The actual choice of suture material shouldn't matter at your stage. For me. This is just again, cos I say this teaching program is also about making doctors and yet ready for the things that I was never taught. This is the kind of path that it is. That's why I've mentioned about like repeat. Um The main thing here is about knowing your size is you can always put, justify putting in a nominal absorbable in a child. If you say it was a dirty wind, I didn't get to clean it at the theater. I want something that's not absorbable. Very justifiable. The main thing from this question is sizes. OK. Yeah. Final question. We've got an avocado hand. A patient's cutting an avocado. So the last the flexor on one of their middle finger, the FDP is the answer Tendon is damaged. What clinical examination would you expect? I, OK. Does everyone know the abbreviations of putting in the answers? Is it the where zone one? Is this zone one? Um Last time one? Is it see three ounces? Is that one thing? OK. So it's either C or A. So that is it C always A A Yeah. Yeah, because if they, if that's correct, I, you're overthinking, here's your zones and here's your anatomy to help you. So the cut is here. So they've gone, they hold their avocado and their knife has gone hair. Oh That, so remember your FDP, your flexor digitorum fundus. Is your longer tendon that goes to that to your distal phalanx goes through the middle of your F DS that is split down the side which attaches to your middle pharynx. So by that logic, if you have cut in the distal in zone one and you've cut over the distal pharygeal joint, what can't you move the distal, the D I PJ? If you had a zone two and you've gone through your F DS, that's where you may not be able to bend at your proximal joint. But you may still be able to, if your FDP, it's unlikely cos that all you can see from the picture of where it's going, where it splits through the middle. So you probably have lost both if you're unable to flex at that joint and you're holding it in extension, you may have a weird deformity, but they usually are holding it in a very shady position. La la down here. You've got your own common tendons, got your lumbar, got the in side. This is where you're struggling to flex up the M CPJ. But in zone one, you flex the zones think the lines of your palm, 12345, it's much easier. Some are separate, some are all separate but 12345 in the wrist. And that way you can help in what tenders are damaged. But in this one, it's definitely your FDP happy, not happy, happy, right? This is your final ever scenario. We've already done an A two E today. So I want you to bear this in mind that this is a hard scenario and it may be helpful that you all work together. Ok. Graham is doing the lights on the ward. Um He's been electrocuted. What do you do? Grabs on the floor for danger? Yep. So um he was touching some wires on the wall. There's no imminent danger to you. He is not touching anything electrical at present. He is on the ground alone and it's concrete floor. Um, what are you gonna say? Can you hear me? Yeah. Gram. No response louder. No response. Graham's not. Yeah. Yeah, you can touch him. He's not touching anything electrical. Yeah. Do you want to shake him? Trapezia? Uh, squeeze. I am very much a sterile r kind of girl if you ever see me, I had a girl who had a seizure the other day. Graham, can you hear me? He's got a response. Which one first? How are you? Good to assess Graham's breathing. And what are you feeling for and looking for? Nothing's moving? You can't feel anything. Yeah. Checking for pulse, nothing. OK. Well, you call emergency while try. Oh no, you go and so you're all on your own at the moment. Shout for help. Shout for help. And what are you shouting? You're in a hospital? You're in a hospital. He is on the ward. So we're in England. We don't say crash call. We say what do we call? It's quite a rest school. What, what that news 11? What do we call it? A peri arrest school? You know, we've been watching too much Grey's Anatomy. So, yep. So um I'm your nurse, you've put out for help. So you're doing your basic life support all on your B LS. Anyone on their I LS. Ok. So we're very much looking to B LS. Good. I'm how to do the slide. Danger. Well done response. Good, gentle shake. I wouldn't do. I would stick to the sternal, rubbed py. Squeeze, send for help. As soon as I would have seen this, I would have shouted for help if you were alone. Help is, is always better to call genuinely. Yesterday. The nurses witnessed a seizure and just called me as the en TSH O and didn't pull out the buzzer, pulled the buzzer. They would rather, I'd rather they shout, I shout at someone for pulling a buzzer unnecessarily and they don't do it, trust me. So pull the buzzer have no show. You're an F one soon enough. Pull the buzzer airway. We've looked, look, feel, move. So look, feel for the chest moves. Listen to that. Um Don't we would write about c spine. He's electrocuted to me again. Have had ac spine from the bla hyperextension. So make sure we're doing a jaw thrust. Um The main thing we don't, we, we've established there's no pulse. Get on the chest. Are we all happy with chest compressions? Have we had to go on the mannequins? Usually I do steal a mannequin for this. So, um one of you is gonna be on the chest. So you're all doing this maintaining 32. So you've actually delegated a nurse. What else can you do? You're af one you're going to be I LS trained to get your A LS. So someone's on the chest going at the defibrillator. Where will you find it on the walls of the, it's a little box with a heart on it, but also on the walls, you've got the, um, Creche trolleys, Creche, um, which are red and have them and have the stickers ready to go. Where do you place your stickers? Yeah, roughly there. If you're confused, what can you do? It's literally on the stickers. Just look at the stickers and where they'll put you. So they'll tell you. So you've attached the stickers but they're doing CPR in the middle. What are you gonna do? Are you gonna move them? No, you're gonna go around them. You can, if you're doing, you're 30 to 2. So someone will give them respirations. But are you just going to give him mouth to mouth? We're in the hospital. We've still got Yeah. Yeah. Yeah, we've got, we're on the W or we can do the Yeah. What do we wonder what? It's very simple. One bag, valve mask, bag mask. But we've got 50 L going through because it's an emergency. If you're on your own, you're going to use your CS shape, clenching the jaw into the mask and squeezing 30 to 2. Remember you say and you count out loud. 28 29 30. Squeeze. Squeeze. So fully squeeze the bag just a little bit and then you carry on with your CPR, very important to have open communication. Always communicate when you're tired, when you do your A LS courses. When your F ones, your hands will hurt, you will be tired. It's a lot of CPR, CPR is tiring. Always say when you're ready because the best thing is that continuous chest compressions, never stop. Always have the next person ready. You're hovering over them, ready to go and start, always ready. So you've got someone on the airway, you've got oxygen running. This is the ad box ready to go and we've got stickers on like this. What do the stickers also do? Apart from shocking people, they measure the rhythm and so it goes and so important to get familiar with these, you'll have them on your courses, plug in the stickers, press the on button and then it will start talking at you and it's great and it will say pause for a rhythm check. So you go off the chest and this comes up. 01 15 is shock advised. He's definitely Graham's not got a pulse. Where are we feeling for a pulse centrally carotid femoral as well when you're um in cardiac arrest as and F one, your role in the er cardiac arrest team will be to want to take the time every time we check a pulse or you could be on a two point pulse check. So someone should be feeling the carotid, someone should be in the femoral at every pulse check just to ensure whether there is this validation, whether we're continuing, whether this person is person is still in arrest. So you confirm two point check that there is no pulse. You've got this rhythm. What do you do? Ok. Vagina you take, why would there be regular sinus but just really slow? That's it can be bradycardia can lead to an arrest. Your heart is pumping. Basically, there is a reason this person is dead cos they're dead. It's um, pulseless electrical activity means that the heart is still functioning somewhat. There is still firing cos you've gotta think of your causes of your, your four Hs and your four Ts. Um, it could be hyperkalaemia. This is a reversible cause that's caused a disruption of the electrical activity that stopped the heart beating. This is reversible. So there may still be electrical activity. There may not be a massive clot that stopped the heart and there's no blood going to it. So that's why it's dead. So that's why you can get ap ea which is why this person is dead but there is still electrical activity. Mhm Yeah. So they're dead. They've got electrical activity. What do you wanna do? Yeah, we've given the drug and as the F one, you're documenting the time, exactly, this was given reassess, keep back on the chest. As soon as you get this back on the chest, you've got someone on access, you've got someone on airways when you arrive, when you will be on an arrest team. I don't know if any of you have shadowed or been on that. The first thing they do is everyone introduce them each other at the beginning of the day and you define your roles if you don't wanna arrive and they go, oh, you're on access that because the team leader has to make sure everything is going on. So make sure you establish that early and say who's gonna be on the chest when we first arrive? So your back of the chest we're carrying on AE D then comes at us. OK? Pu pulse check advised. Um And so they're gonna recheck the rhythm. This is your rhythm that comes up. OK. And shock advise. Yeah. What is this rhythm? It's VT ventricular tachycardia. So your two shocker rhythms are VT and correct. Your non shocker rhythms are and pa correct. So shock, we give a shock and because it's an ad cos this is B LS, it gives it and it comes back to life. All right, you save the day. Well done. These are the main things to take away for what you do in ABL S after you have done CPR, what are we going to do? We're gonna reassess, we've probably done a lot. We wanna start from the beginning and make sure they're stable in every other way. You don't just stop as soon as you get a pulse, you start again and you manage them as per BI A LS, whichever one. But the main thing about A LS is as well doing your A two E shadow arrest get involved because your first one take a coffee after a cup of tea. Cos they're big events and I don't think people say it's F one's, well, mine was very different cos I was COVID year so, like they were horrible but they're really traumatic and reflect on them. And if you can see one do it early and talk to the registrar about it. But they have really important learning events. They're amazing when they go, well, you lose more than you safe or I have again, covid's PTSD, but it is really exciting but awful at the same time. So talk about it and reflect, but it's good. You'll be fine and I hope you're already on that. Very somber note cos that is the end of the acutely ill patient cos you've saved 10 li nine Lives cos I was operating for one. I hope you've all enjoyed it. Um, thank you very much for everyone who's come in person. Everyone online. I've enjoyed teaching it.