You'll definitely enjoy our upcoming plastic surgery session! Also, a great way to revise for exams, hosted by medical student Amber Ghani.
SUPTA Plastic surgery
Summary
This online teaching session is designed to provide medical professionals with an overview of plastic surgery, including aspects such as wound management, skin grafts, and tissue expansion. We will also explore the principles behind primary and secondary wound closure, understand the reconstructive bladder, and the technique of skin grafting. Fundamentals of burns and hand trauma will be included. By the end of the session, attendees will have a comprehensive understanding of plastic surgery and its applications to medical care.
Description
Learning objectives
Learning objectives:
- Attendees will be able to explain the different principles of wound management.
- Attendees will be able to identify and assess skin wounds.
- Attendees will be able to differentiate between primary and secondary wound closure techniques.
- Attendees will be able to explain and contrast skin grafting and flap techniques.
- Attendees will be able to explain the use of tissue expansion in wound healing.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
Yeah. Uh, just checking if you can hear me. Yeah. Yeah. Hi, everyone. Thanks for coming. Uh, can I just check if you can hear me? But if you could just message on the chat, that would be great. All right. I think we've waited a couple of minutes already, so we'll just make, we'll make a start. Um, so, hi, everyone. I'm Rishi. I'm 1/4 year, uh, integrating medical student at the University of Leicester. Um, also on the National Committee for up to as a, uh, as an education lead. So, so up to a bit about soup to first. So soup to is a national peer teaching society focused on delivering surgical education, uh, two students all across the UK. So, um, before we get into it just, you know, big. Thank you to our partners and sponsors. So, what exactly is plastic surgery? So when you ask, what, when you ask a layperson or even some, you know, medical students, what plastic surgery is all about? A lot of them will, you know, go back to the public misconception and, you know, they think that plastic surgery is all about nose jobs about facial surgery. You know, uh, fillers, Botox tummy tucks, you know, be, be else and stuff like that. But actually, plus there's a lot more to plastic surgery. Aesthetic surgery is a small part of plastic surgery and the other, you know, self specialties within plastic surgery and that will be burn surgery, craniofacial, uh, hand trauma, microsurgery and even pediatric related uh plastic surgery. So plastic surgery actually originates from the Greek word plastic or plastic owes which translates to English, which in English, it translates to mold or to form. So, plastic surgery in essence is the surgical specialty involving the restoration, the reconstruction and the alteration of the human body. And it is the only surgical specialty that is not confined to a singular part of the body organ. So plastic surgeons, they're defined not on where they operate, but on how they operate because they use certain skills to perform the procedures. And that's something I find really cool about plastic surgery. Another thing that I really like about plastic surgery is that there's a lot of crossover with other specialties. So you get to work, uh you get to work with other surgeons or other doctors in different specialties. And you, plastic surgeons commonly work with TNO surgeons with the ent surgeons with breast surgeons, neurosurgeons, uh max facts, surgeons, oncological surgeons and even dermatologist. Um I read this quote, I think a couple of months ago where they said like a plastic surgeon is a surgeon surgeon because they're involved in so many, you know, different types of procedures. And that's something that appeals to me. So the intended learning outcomes for today is um talk or lecture wouldn't call it. So firstly, we'll talk about the principles of wound management, specifically cutaneous wound management. Then we'll talk about burns. The reason I'm focusing on these two learning out these two primary learning outcomes is because they're rarely covered in medical school. But they're quite important when you know, you embark on your, your, you know, your your foundation year, some of the some plastic related uh plastic surgery related content such as hand trauma and skin cancers. I will not be covering in this, I will not be covering uh those in this lecture because this should be already covered quite well in your medical school, uh syllabus and in the other lectures delivered by soup to. So let's talk about the principles of cutaneous wound management. So that's basically how do we manage skin wounds. So firstly, a bit about skin wounds. So skin wounds are incredibly common and there's a wide range of etiology. So a lot wide range of positive factors and this could be because of infection trauma and even surgical incisions, most of them, as you probably know, will heal without specialist input or intervention. Now, the three main principles for wound management and that is to keep the wound clean protected and to create a nice environment to facilitate wound healing. So let's talk about, you know, just assessing a wound. So when you know, when we're assessing a wound, you need, you need to take comprehensive, you know, history from the patient. You need to identify the causative factors and the mechanism of that wound. Because wounds can type of wounds, they can be, can be simple in nature, they can be large, they can be complicated, they could even be infected. Um And you also need to discuss with the patient, what are the aims, you know, for treatment? Because, you know, patient, for example, if you have an extensive wound to a limb, the patient might be very keen or might be, you know, quite um keen on, you know, preserving it even if it's not possible. So it's important to take the views of the patient and obviously, senior clinicians specifically burn consultants. So in more complex cases where they're, where there's, you know, severe skin, skin injuries or skin wounds, we will need surgical closure and reconstruction. And the reconstructive bladder is governed. Uh the reconstructive bladder is what governs, you know, the principles for surgical closure and reconstruction. So the surgeon, the reconstructive bladder is a step wide progression of wound management. So, on the image on the right, that's the reconstructive bladder. So we'll start with the first picture. Uh you know, we'll start with the first um the first level basically on the reconstructive bladder. So I labeled over the number one that is secondary in tension and this occurs when both of the sides of a wound unopposed, meaning that they're not in contact with each other. And we and usually plastic surgeons will leave the wound like that. And that means that healing occurs from the bottom up. So, healing happens from the base of that wound and it works its way upwards. For the second intentions. There are four stages of healing. So firstly, you have him a stasis where you get basically a blood clot and a scab. And this prevents uh you know, a lot of blood loss. And the scab also prevents introduction of pathogens, therefore preventing infection. You also have an inflammatory process occurring there and that's to remove any cell debris and pathogens. Now, graduation tissue, as I said, you know, it starts to from from the base up and as regulation tissue forms from the bottom upwards, it eventually reaches the level of the epithelium. And that's where you get re epithelialization uh at the level of the original epithelium. And that's basically remodeling. Now, my myofibroblast there, a special type of muscle cells containing acting uh fibers and they play a role uh in contracting the wound basically to keep it closed. So, label two and three, that's proper intentions. So label number two on the image that's primary attention. Label number three is delayed, primary in tension. So primary in tension. How does it differ from secondary in tension? So, in primary in tension, the edges of the dermal edges of the wound are in close contact with each other. And usually this happens by scootering. Uh the top, the top of the top most layer of the epidemics together to get the edges close together. And that means primary intentions, wounds tend to feel a lot faster than secretary in tension the same four stages. So, hemostasis, inflammation, proliferation and remodeling, uh you know occur, that's the same as what happens in secondary attention. The end result of healing is complete, written to function and minimal scarring. And therefore, you could say that you know, the outcomes of primary in tension can you know, they tend to be better than that of secondary in tension. So let's just have a look at this case here where this patient has um a basal cell carcinoma, an image a and you can see the preoperative markings made and after excision of the basal cell carcinoma, uh just basically the surgeon just switch it up the top most layer of the epidermis. Um and that was probably in tension and you can see how it was closed. So just to compare the prime, compare primary versus secondary in tension. So in primary in tension, usually, um you know, it's when it's a surgical incision, it could be other things as well and sharp object. Um But you know, in our experience, at least the medical student experience very common. It's a surgical incision, you get a clean narrow incision. Whereas wounds where that's where you know, you take secondary closure to close it up. Uh they tend to be broader, especially with a broader base. And in primary attention get you get minimal scarring, it looks very neat. In secondary closure, secretary attention, you tend to get a wider, more visible scar. So we spoke about what primary and secondary intentions were. Let's talk about skin grafts and skin flaps. So these two techniques, our surgical techniques used by plastic surgeons when a defect or a wound cannot be closed by primary or secondary attention, usually because the wounds are too big. Now, two key differences. Well, key difference, sorry between uh skin grafts and skin flaps, uh skin graph, they receive its blood supply from the recipe in the side. Whereas climb flat, they tend to bring its blood supply from the donor side. Um As I can flaps are commonly used to cover, you know, uh large areas. Um but there are some contraindications and these are infections, skin infections to either the don't uh at the donor side. Uh previous history of chemo or radiotherapy, uh ongoing skin cancer or certain patient factors such as poorly controlled diabetes. So, moving back into onto the the reconstructive bladder. So on the image, we have number four, on the image level, number four, that's the split thickness skin graph. So there's two types of skin grafts over here. So number four it's split thickness and the split thickness graphs contain the whole epidermis but a varying thickness of dermis. You know case by case on a case by case basis, a little bit of the dermis is left at the donor site to encourage re appetite, ization and split thickness. Skin graft are typically used when the skin defect is too large for a full thickness skin graft in the bottom left image, you can see a a device that is used for skin grafting and that's that's called a dermatome. And on the image on the right, you can see how that process is being done now onto the um onto according to the image number five, that's the full thickness skin graph. So it contains the full thickness of the epidemics and dermis. And it's commonly used when the recipient site has optimal vascular availability. And the reason we need to ensure that, you know, the optimal vascular availability is because full thickness skin grafts tend to require a lot of energy. And if you don't have optimal vascular vascular ization to that area, then your graft is more prone to fail. Now, once the graft is harvested, there is no skin, absolutely no skin left at the donor side. So the donor site needs to be closed using sutures. Um And unlike the split thickness, skin grafts, the full thickness skin grafts are harvested using a scalpel and any subcutaneous fat below the dermis is removed. So, mitch number six, you can see kind of like a balloon under the skin and this method is called tissue expansion. And uh this happens when, so let's talk a bit about, you know, when this about how this technique is used. So tissue expansion is used when you need the skin, you know, to kind of to grow. Now, the skin responds very well to mechanical stress, you know, as you know, during pregnancy, um you know how the skin just expands, you know, it just doesn't just split or anything like that, it expands quite nicely. So we're using the same principle over here. So, you know, uh one case that I saw actually was when a patient had basal cell carcinoma on his scalp. And so it was removed, it was quite a big, it was, it was quite a, you know, big, significantly sized um BCC. And when that was removed, obviously, you know, the patient didn't want um you know, a patch of boldness over there. So they put a small tissue expander to kind of grow at the skin around it. And, and that allowed the hair to cover an incision was then made and the skin was brought over and that allowed, you know, the patient to not have that patch of boldness. So you can see something like that in the image at the bottom. Obviously, this is a lot more significant than what I saw, but it's the same concept and the key part to what I was just speaking about is by expanding the local skin surrounding a defect. The wound tissue coverage is provided and the tissues of similar texture and color. Now 7229, we're talking about flaps. So on the image, uh numbers for number seven, that's the local flaps. Number eight is in reference to the regional of pedicle flaps. And number nine is reference to free flaps. So we'll talk about local flaps first. So local flaps are harvested from a contiguous site, meaning that it's, you know, immediately adjacent donor site. And the recipe insides are immediately adjacent to each other. And local flaps are commonly used for facial defects or fingertip injuries. Um Regional flaps, they're harvested from the same anatomical region, but the edges are not directly adjacent. So the donor side and recipe inside that within the same area, but they're not adjacent to each other. However, like the local flaps, the vasculature vasculature from the donor site is still preserved. Now in free flaps, they are harvested the donor site and the recipient sides are, you know, are not within the same anatomical region at all. Um And over here, the vasculature is not preserved. This, this means that the fashion cutaneous artery below from the donor side is basically removed, it's separated and it's re attached to the donor side or reinvesting most using microsurgery techniques. I'll give you an example of what a free flap looks like So over here, we've got a few common examples of free flaps. And on the image on the right over here, that's an example of the D I E P uh listed number listed first. This is the D I E P flap used for breast reconstruction after uh after mastectomies in breast cancer. So, in this D I B flat, basically, skin subcutaneous tissue uh removed from the abdominal region and they removed specifically from the abdominal region because you know, there's a higher uh there's more fat content basically and that that portion of tissues used to reconstruct the breast. So we spoke about the principles of wound management. Now, let's talk about burns. So what is a burn? So burn is, is you know, any resulting damage to the skin and underlying tissue caused by external sources or substances. So why are we talking about burns? So, burns are a major cause of injury and death worldwide. And mortality in burns is increased as you expect with larger burns, increasing age and associated inhalation injury. Effective management is important especially MDT approach is important uh you know, for effective management. Another reason burns are really important to talk to and we don't receive much education on burns in medical school. But we're talking about this today because burns can have a devastating effect on, on the physical and psychological uh aspects on a patient. I can also lead to chronic disability. So let's talk about the etiology of burns. So the most common type of burns are thermal burns, right? And there's three types of thermal burns that's contact flame and scalding. So contact burns happen when, you know, say give you an example, you know, when especially classic scenarios when an elderly person falls, you know, and uh then, you know, then, then either not unconscious for a couple of hours and they're in contact with the radiator and that's a form of contact burn. And you know, that's also relatively common presentation. Aflame burn is when you come direct into direct contact with fire, basically. And scalding is when you come into contact with really hot um of, you know, gas or fluids, you also have electrical burns, you have friction burns and you have chemical burns. But like I said, thermal burns are the most common form of burns. So I've already said this, but burns are a common form of trauma. This is, it was quite, this is, this is quite interesting to me. So the most common place they burned is actually at home. Uh in the UK, they're about 250,000 burns each year, 10% of which require hospitalization. And in the UK, they're about 300 deaths or so uh due to burns. Now, Byrnes are also very common in both adults and Children. And you can see the common uh types of burns in both Children and adults. And like I said, term burns are the most common. But in Children love, proportion of burns tend to be because of scalding. So, uh you know, need to contact with hot gasses or hot fluids. And adults, it tends to be flame burns. So let's talk about the pathophysiology of burns. So when it comes to burns, there's both a local response and a systemic response, we'll talk about the local response first. So the local response is governed by this model called the Jacksons burn wound model. And it states that the three zones, uh you know, when someone is affected by a bird, let's talk about the first zone in the image, the zone of coagulated necrosis. So this is the zone where this is the area where it's closest to the heat source on the injuring agent. And because of that, it results in immediate coagulation of the protein. And that's irreversible cell death within the zone of coagulating necrosis immediately beneath. That is the zone of stasis and damage to this area is less severe and potentially salvageable in his own of stasis circulation is compromised. And if less, if left untreated, right? Because you know, burns are dynamic and they tend to progress even after the initial burn. So if it's left untreated, the zone of stasis can also undergo necrosis. And below that, you have the zone of hyperemia and that's where you get a lot of blood flow because of inflammatory mediators which cause, you know, um which cause uh significant vasodilatation. And so you get more blood flow to that area and that promotes, actually promotes healing and the form of granulations issue. So we spoke about the uh we spoke about the uh local response. Now we'll talk about the systemic response. Uh Sorry, one second, let me just bring up my notes. Yeah. So let's talk about what happens. Uh So is the stop systemic response? It affects different parts of the body. We'll talk about the cardiovascular system first. So because of, you know, severe in severe burns, um you tend to get an altered vascular permeability, meaning you get a lot of leaky vessels and a loss of intravascular proteins. Now, additionally, because of the burnt area and it's more exposed, you tend to lose a lot more fluid due to evaporation and a lot more fluid tends to be trapped in your third spaces. So you're dehydrated because of the increase in evaporation and also fluids moving into the third spaces. So you get dehydration and adama. Now, dehydration, adama can cause systemic hypertension. Um we'll go on to talk about respiratory. So how it affects the respiratory system. So, because of all the inflammatory mediators, you know, uh sent out after burn after, you know, after a patient suffers from burned, you can get inflammatory in these broken constriction. You can also get, you know, inhalation injury and that's something we'll talk about a bit later in this lecture. Um in terms of your uh so it also does affect the metabolic um of your body. So your basal metabolic rate can increase up to three times post burns. And um you can also, you can also because of that, you can also get a muscle breakdown and finally how it affects your immune system. So you get a huge release of your stress hormones. So this includes your cortisol, your catacholamines, right? And because of a huge surge in your stress hormones, you can get a suppression of your cellular immunity. Also, you tend to get a loss of your gut barrier function. And this permits translocation of bacteria which might lead to sepsis in an already compromised body. So we spoke about the pathophysiology and then we spoke about, we spoke with the fat fatty physiology, the local and the systemic responses. We'll move on to the assessment of burns. So when assessing a burn, there's two things we need to consider. Firstly, the totals body surface area, the burner is affecting and the depth of the injury. So we'll talk about the total body surface area first. So the three ways to measure the total body surface area. Um the first is using Wallace rule of nines. And this is basically when the adult body is divided into anatomical regions that represent nine or multiples of nine. So I'll show you an image before we progress any further. So this is Wallace rule of nines. And so basically your head in your neck region, you know, accounts for 9.5% your lower limbs, the front and back account for 18%. Your front torso is another 18% of your total body surface area. So that's how they calculate this Wallace rule of nine can be used to calculate the total body surface area for burns. Another rule is the palmer rule where you take the patient's hand, key emphasis on the patient, not your hand, the patient's hand and the patient's hand represents 1% of the total body surface area. So you can use that to measure, you know, the burn area. But you tend to use this more in small and non confluent burns. And the last way to measure it also body service areas by using the London Broader chart. So this is the most accurate method of estimation. Um and it's specifically used in Children because there's a separate shot designed for Children of differing ages. And it takes into account that adults and Children have different body proportions. Now we'll talk about the depth of injury. So if you remember earlier, I said that wounds, they tend to be burn wounds, they tend to be highly dynamic. So they changed nature quite a bit even after the initial burn. And that happens even after even, you know, in the first 3 to 5 days after a burn. So in terms of assessing the depth of injury, that's an ongoing process, and you know, most doctors handling burns will reassess the depth of burns. Uh, you know, every day for the first five days after the burn. But how do they assess the depth of injury? They assess the depth of injury based on the color of the wound, whether there any blisters present, whether there's a capillary riffle and whether there's any sensation. So this is a table over here. Uh, you know, I'm not going to read out the table, but you know, this table kind of summarizes how you would classify the depth of their wounds. So a big one would be obviously color. So epidermal burn burns would be red, dermal burns, they tend to start off with a pale pink and as they go deeper, they tend to get more red until, you know, eventually they turn white and when it's white, it means there's, you know, full thickness, it's a full thickness burden another big one um is sensation, you know, if there's no sensation to that area, then you know, it's probably really bad and it's either the the world of full thickness and to differentiate, you use the color. So this is another image which kind of, you know, explains what I what I was talking about. But they tend to class in this picture, the classified burns according to your typical 1st, 2nd or third degree burns. So your first degree burns tend to affect only the epidermis. Your second degree tends to affect the dermis. Um So in the previous picture, there was, you know, partial and full dermis, uh sort of partial and uh uh mid, sorry, superficial, mid and thermal and full thickness would be your third degree burns over here. But third degree, this picture is a bit inaccurate because it says it shows red over here. But third degree burns actually white whitish and I'll show you a real life picture. So in this patient over here, you've got all three degrees of burns. So along is, you know, closer to his hand, you will see, you know, a first degree type of burn, you know, and um you see some second and when, when there's a complete whiteness over there, that's third degree that those are third degree burns. So let's talk about the man acute management of burns. So uh the acute management for severe burns is based on modified A TLS algorithm and then consists of basically 33 elements. So you've got your primary survey, which is your A B C D E, then you've got your F A T T, which is kind of part of your acute management. And then you've got a secondary survey to make sure you have not missed anything else. So we'll talk about your primary survey first. So with your primary survey, your priority is to ensure that, you know, the airway is patent and your cervical spine is are protected. This is also where you assess for you know, any inhalation injury, if there is suspicion of poor inhalation of, of inhalation injury, poor oxygenation, poor G C S, um or even to facilitate, uh you know, safe transfer. That is when you want to interview intubate. Now, in burns, especially there's a very low threshold for intubation. So if you're not sure whether to intubate intubate, it's probably safer to intubate. That's the rule of thumb in burns. So now after assessing for airway and making sure the c spine is immobilized, you want to go on to, you know, breathing and ventilation right over here, you want to give the patient high flow oxygen. Um and you want to assess the breeding of the patient. Now, especially when burns, they tend to affect the upper chest or neck area when it's a bad, you know, bad burn, you can get the skin can kind of contract and that might affect the breeding actually. So if that, if you see your patient struggling to breathe and there's burns to his chest, you might want to perform some nickel and escharotomy where you basically make um you make an incision, a full thickness incision to kind of separate that contracted tissue to allow the patient to breathe a bit better, then you want to go down uh you know, on to see which is your circulation. So you want to check for, you know, pulse is you want to get IV access. Um You can also do bloods over here and prescribe IV fluids. So, if you recall earlier, I said that burns patient's, they lose a lot of water um because of increased evaporation and there's fluid lost two third spaces. So you want, you want to uh you know, rapidly prescribe viruses IV resuscitation, then indeed, that's disability. You want to check the neuro status of the patient. You want to do, you want to check, you know how uh you want to do a G C S examination or after examination, you want to check the patient's glucose and people really pupillary reflects and then moving on to e you want to fully x expose the patient and you want to, you know, assess any, whether there any other injuries uh to the body, any other burns to the body. And if there are any other injuries, because I'm still unsure of the mechanism, uh you know, could it be a blast injury? So there might be other parts of the body that are injured. So we spoke about the primary survey briefly, we'll move on to the F A T T, so F A T T stands for fluids. So like I said, you wanna, you know, carry out uh immediate IV fluid resuscitation if the total body surface area is more than 15%. Now, the fluid intake is calculated based on the Parklands formula and the recommend fluid is the Hartman solution because that, you know, closely mimics the, you know, the electrolytes concentration seen in blood plasma. So the formula over here is, you know, 3 to 4 millimeters, we're taught four millimeters times the total body surface area burned times the weight of the patient. So for example, you know, we'll take an example. We've got an 80 kg man and he's got 20% of his, you know, of his body is burnt. So that's how we calculate. So, you know, based on that, we'll calculate his, based on the parking's formula will calculate how much fluid to prescribe him. So 4 mL times 20% of the body burden times 80 kg. That's his weight gives you 6400 mL, which also equates to 6.4 liters. So now the Parkland formula also state that states that half of that volume needs to be given in the first eight hours from the injury and the other half in the remaining remaining 16 hours, right? So 3.2 liters in the first eight hours after the injury and remain 3.2 liters uh 16 hours uh in the remaining 16 hours. But it's important that you know, I said from the injury. So if a patient was burned, say at 12 noon and he only presents at four PM, that means half. So 3.2 liters need to be given in the remaining four hours in that first eight hour period. Okay. That's just something you need to stress over here. So we spoke about fluids. So algesia, so obviously, burns can be extremely painful, you know, as you'd expect. And so you prescribe IV morphine to adult patient, an intranasal die morphine, two Children. It's just something to look out for, you know, when you're prescribing morphine. So patient's might be at risk of respiratory depression and this is especially important in burn patient, you know, where the respiratory system are already, we compromise just so moving on to 30 stands the third alphabet first E that stands for tests. So these are the tests you want to carry out in your patient. So you do bedside investigation, firstly, right with them into bedside blood and imaging. So bedside investigations, you know, as you imagine you want to do your basic obs your BP, your analysis, you want to check for glucose. You want to also do an E C G to assess, you know, how is the heart coping with, you know, a severe burn. And also you want to do an A B G to assess oxygenation, you then perform blood, your standard blood. So you're fpc's using these LFTs your group and saves clotting profile. The specific ones that you need to look out for here are CK, which is your measure of muscle breakdown. So when we spoke about the systemic response to burns, you get, you get an increase in your metabolic, your basal metabolic rate up to three times. And that means a lot more protein's broken down. So you want to monitor your CK levels. Uh you want to monitor your carboxyhemoglobin levels, right? Um uh And you want to assess, you know how oxen, it, how much oxygen is within, you know, within your, your red blood vessels. How, yeah. And also you check your cardiac enzymes to assess how your, how the house doing. Finally, you also do a chest X ray in all burned patient's, you could consider a chest ct, but that depends, you know, on the specific nature or the mechanism of the trauma bronchoscopy can be done to assess the, you know, your upper airways. And this is especially done if you're suspecting inhalation injury. So let's move on to the final uh tea with the tombs. So the the two tubes you want to consider, you know, placing intergration would be your catheter and this would be important to measure urine output. And that also helps, you know, if you're thinking sepsis, you know. Um so it's kind of a good measure to do that. Um And we spoke one of them, we spoke earlier about, you know, the systemic response to body. So you, you can get a loss of your natural gut barrier. Um You can also get gastric alias, that's a potential complication of burns. And so to decompensate the stomach, you want to insert an N G or N J T, this also helps with feeding because you want to keep the patient know by mouth. So um we've spoken, we've spoken about the primary survey. We've spoken about the F A T T. Now we'll move on to the secondary survey and now within the secondary survey, that's the ample history, head to toe examination, which we've already done in the primary survey. But you do it again to just look for any injuries that you might have missed. We'll speak about, you know, the importance of tetanus prophylaxis and importance of documentation. So the ample history. So this is where you get more of a history from your patient. You know, initially, you might not have a chance to, you know, probably talk to your patient or get a good history from them. So you'd ask the patient for any allergies uh medication. You ask therefore, you know, any relevant past medical or past surgical history when they did last eat, you know, and uh you want to buy this point, you want to, you know, definitely know the mechanism of the burn. Like I said, you also conduct another head to toe examination. I know as part of your 80 assessment or your primary survey, you probably would have done that. But as part of the modified a TLS algorithm for burns, you know, you conduct another head to toe examination uh to look for anything that you might have missed. Our burn sides are particularly susceptible to tetanus infection. And that's why tetanus prophylaxis um is administered. And finally, I've, I've said this a couple of times already, but burn wounds are highly dynamic in nature and they can, you know, change even up to five days after the initial burn. And that's why proper documentation and photographs are important to kind of assess the changing severity and by proper documentation and photographs, you also get, it also helps you uh with management. So that's the end of my presentation. So just to quickly recap, we spoke about the basic principles of wound management and then we spoke about, you know, burns. It's, you know, uh it's the significance of burns, the etiology, the pathophysiology. How do you assess burns and then finally, how you manage them? Thank you very much for listening. Happy to take any questions if you, if you guys have to uh the slides and recording will be uploaded, uploaded onto a medal after. So if you're wondering, all right, thank you guys for coming.