The Mx of the Acute Major Burns Patient

Welcome to Poplast UK. Hello and welcome to Poplast UK. Now in today's episode we're talking all things are cute burns And I'm delighted to welcome Mr. Christopher Lewis, a consultant plastic surgeon who has a special interest in burns and who works in Newcastle Who was also the training program director for the North East of England is the J. Pras deputy editor and the special interest group chair for BAPRAS 4 burns. Welcome to you Mr. Lewis. Thanks very much for the invitation. Great to have you. So to begin with, what is your approach to a patient with a major burn presenting into the emergency department? I think for anyone who is a parry exam and preparing for vivas and even those who are going into a day one consultancy, the approach that you should have with any major burn in the ED should follow the principles that you've been taught on your EMSB course. So focus on airway management, liquid recitation, pain control, looking to prevent infection and then early triage to an appropriate service. You know, and that might be your service or it might be that you're working in a burn facility or in a DGH that doesn't have burned expertise and you need to safely transfer that patient elsewhere. So, it will very much go along the A to E principles starting with your airway. So are there any signs of airway compromise, any horseness, any stride or course you're going to be doing this in conjunction with the anesthetists who will be down there assessing the patient with you. We should have a low index suspicion of having an airway injury and airway edema because that can worsen early. I mean, you need to involve anestists very quickly. And then, you know, again, for the purpose of vivas in the exam, if you're talking about airway management, you're talking about using large caliber uncut tubes to accommodate swelling. You need to be thinking about how the tube is going to be secured and whether you need to fixate that to their teeth using dental wire or if you need to involve max facts. That's quite an important thing that it has for in exams, but also it's very important in clinical practice considering how a face is going to swell or when patient has, you know, 30 liters of fluid going into them along with airway to make sure that they don't have a cease by injury. For instance, if they fall out of a window escaping a house fire or if they've had an electrical burn falling off a metro train. And then moving on to breeding. So looking at looking at their chest wall, have they got circumstantial burns, which might be impairing the ventilation. Speak to your anesthetist who might be at the head end in jubiting. Are they having problems ventilating the patient? What are the ventilation pressures like? If they're difficult or they're getting worse, is that because they have a full thickness constricting burn around their chest that needs urgent release? Remembering that a chest burn doesn't need to go the whole way around the chest to cause problems with ventilation. Making sure that you get to your carboxy hemoglobin level. You put on a satz monitor that can't distinguish between oxy hemoglobin and carboxy hemoglobin. The only way you're going to do that is with a blood gas. So do a blood gas and they're off. That can also help you see if they have cyanide poisoning because you can look at their lactate level and correlate that with how they are authentically. And then circulation to making sure that they've got good, wide or access, sending off the relevant bloods. And then thinking about fluid recitation, do they meet the threshold for fluid recitation? If so, what form were you going to use? What is the age of the patient? Are they going to need extra fluids as a child and then monitoring their urine output to make sure that the fluids are meeting end organ perfusion? The rest of it really is then what you'd expect. So disability, checking their GCS, looking for any signs of carbon monoxide or cyanide poisoning which you should always consider in any attended patients. And then finally, you move on to exposing a burn. So sequentially, I'm very particular with my trainees that I don't walk into recess and find a patient who is completely uncovered and getting cold that there's a methodical approach to assessing the burn, exposing a limited time, documenting the burn and its depth and then moving on to another area to keep the patient warm. That would then be followed by secondary survey as well. So, you know, you need to be comprehensive in your approach. So when you're discussing these things in an exam context, it's always about going through that A to E approach. The reason that it's almost forced down our throat is because it identifies the most life threatening injuries first before moving on to the next. And you mustn't get distracted by the burn injury. It's very easy when people see a big burn that they instantly want to work out how big it is and they can miss some of the occult injuries. And that's happened when I was on fellowship that people have walked into an A&E. People have focused purely on the burn and they've missed injuries that the patient has had including serious bind injuries. So always be methodical and always logical in the sequence that you're going through when you're assessing these patients. Then it's all about where you're going to care for the patient, once you've done your primary secondary survey, where are they going to be cared for? Are you going to keep them in your hospital, if you work in a burn unit or burn center, or are you going to need to transport them elsewhere? And there's really good guidelines that are available on that. The British Burner Association has issued guidance on which burn should be managed in a burnt facility, a unit in a center. And those guidelines are available in a document called National Burn Referral Guidelines, which you can Google and you'll find it very easily. Yeah, definitely something every UK trainee at the very least should be familiar with, I think, as you say all those things, often many simple things but together really, really important for managing these often very unwell patients. Thinking about assessment of total body surface area, what strategies do you think are most useful when you're confronted with a patient with a significant burn injury? I think that estimating the TBSA is the most important part of burn evaluation by referring hospitals. That will impact on so much in those first few days of the being repatriated to your service. So if they're underestimated, they're not going to get enough resuscitation, patients will become hypervolemic, they'll be shocked, their burn wound will deepen through the hypertension, and overall they get a poor outcome. But equally, if you overestimate it, so they've got a 10% burn and you say it's 50%, they're going to have massive amount of fluids become very demitus, they get thirst based losses into the chest, they're abdomen, they're limbs, the need for them to have an escrot of me goes up, they're burn wound deepened again, and they get a poor outcome. So I think this is one of the most critical parts that needs to be correct at the first point of contact by a clinician. It's really important, though, that you're only including burn in your estimation, you're not including arithema. So the trick that I use is we take a gloved finger, you run that over and I think that you can't distinguish burn in arithema, and if the skin comes off, then it's burn. But if the skin remains intact with digital pressure, then that's arithea and it shouldn't be counted. So that's almost like a sort of Nikolsky test type thing you mean, but for. Yeah, yeah, exactly. You need to be careful in, you're not going to do that in a very young child and traumatise them, but for the large adult burns, they're usually intubated at the scene and bought a hospital or they're intubated in the early part of their assessment and resusc, then this is something you can do, and that can help distinguish what is true burn and what is just arithema. And then you have a variety of methods that you can then use. Everyone has heard of the rule of 9s, dividing body regions up into 9% or multiples of 9%, but that's not accurate in kids. So in kids, you have to be very careful that you're using age-specific wallets rule of 9s. So generally, that means that for a child who's less than a year old, they have big heads and they have short legs. So a head will be 18% and each of their legs is 14%. And then every year of age, you take a percent off their head and add half a percent each leg. So a child will achieve adult proportions for the wallets rule of 9s by the age of 9. You can use the palm method. People say it's 1%, I think it's recently been found through research that it's less than that, certainly an adult is 0.8%. In a child, there would be 1%. But the most accurate way of documenting all of these is to use a lump-and-browder. So that will be giving you age-specific figures for different body regions, which you can annotate the depth as well as the area. There are a variety of apps available. Obviously, you have Mercy Burns, but there's a whole load of others available on the App Store. You have to be a bit careful with those just because they don't necessarily take into account the 3D body surface. If you're putting all these together, you should be able to get a comprehensive assessment. One tip I would say is that if you get a very big burn, the easiest thing to do is to just work out what isn't burnt. So we can say, right, we think it's got an 80% burn because X, Y and Z isn't burnt. And that way you can get some you can get a quick total for it, just by reversing the way that you're looking at the patient. And obviously one of the reasons, as you mentioned, that calculating the TBSA is so important is to guide us with our resuscitation fluids at least initially. What is your approach to calculating those resuscitation fluids? You use a Parkland formula or something else? So I think in an exam context for FRCS+ you should be talking about Parkland formula and you should be talking about the emergency management of the burnt cause teaches you. There are nuances in formulas and different services, may use different things, but I think the safest thing in an exam situation is that you talk exactly what is taught nationally on an internationally recognized course. So thinking about why fluids are required, you're losing the shrink wrap of the body, you're having leaker fluids evaporation from those moist wound surfaces. You then have to generalize the demer and leak in it, because you've got this whole orchestra and flammatory mediators being moved around, so histamine, prostaglandins, bradykinin, which are causing vasodilation, increasing capillary permeability, so everything is just leaving your intravascular space and going into the tissues. But you also have the impact of oncotic pressure. So if you've got the big, full thickness burn, the oncotic pressure within that denatured skin is pulling fluid out of the intravascular compartment to sequester in limbs, and there's evidence that early deprivation of that full thickness burn can actually reduce your fluid resuscitation because you're offloading the oncotic skin load of all the eschar. So overall you have this combination of adema, evaporative losses, third space losses and shock that we need to account for about giving them fluid resuscitation. So when you are assessing one of these patients in the ED, it's really critical that we have a plastic surgeon there to receive handover from the ambulance crew or the ED crew, so you know exactly what fluids they've been given and also the time of the injury or the presumed time of the injury so that you can be working things out together with your heart and formula. So what I would say for the exam is that you are going to use heart and formula and you're going to be using it as the three meals of arm and arms by their weight and kilograms and times in it by the TVSA giving half within the first eight hours from the time of the burn and half in the following 16 hours and just removing any fluids that they've had pre-hospital fun that the updated guidelines are that we resuscitate adults when they have a 20% and above a burn and for children at 10% and above burn and then making sure that they're catheterized and that you have an hourly arometer so that you can keep tabs. Another really critical thing to remember is that all these formulas, whether it's Parkland or Muran Barkley or whatever else if using these are not an absolute, they are a guideline. They can be then adjusted dependent on the urine outputs. So if you have a urine output of half a milper kilo per hour in an adult or a non-electrical burn that means that you're achieving end organ perfusion, it's safe. But if I come in and I see a patient is being 3, 4, 5 mils an hour per kilo, that's bad, that patient is being over-assuscitated so you need to adjust the formula to accommodate that. Obviously electrical burns are slightly different. We want to make sure that they are well hydrated that we have a higher urine output because of the wrapped amalysis and the risk of myoglobin urea and acute kidney injury. So those patients we do want slightly higher but generally you want to be, you know, looking at the urine output and making sure that it's on points every hour and adjusting your formula depending on what they're appearing. Yeah, I think that's often quite poorly understood sometimes isn't it? I know I've seen people say, "Oh, but Parkland says this" and even though the patients urine output, you say maybe far from what you're aiming for and so it's that recognition that it's just starting point is really important I think isn't it? Definitely. And when patients go to intensive care then these things, certainly here, these things go out the window in there, it's much more based on invasive monitoring and they're looking at different things and they're not purely looking at urine output. So I always find that once they go to intensive care for big burns, I don't really have a much of a set of intensiveists are looking at a variety of other things that are beyond my expertise to say whether a patient is correctly resuscitated or not. Absolutely. So we've talked a little bit about fluid management and we've talked about managing some of those other acutely life-threatening elements that can go with these major burn injuries. What are the other priorities in the first 24 hours when managing these patients? So the priorities really should be focusing on stabilization so whether that is, again, in your hospital or your transfer in the mass wear, preventing complications and then planning for their definitive care and that's very much dependent on the local skill mix and the expertise you have available. We've mentioned already that the BBA has issued guidelines on where patients should be looked after. I mean, I'm fortunate enough that we're in a pediatric and adult burns center here in New Castle, so we're able to have the whole spectrum of patients with burn injuries. But much of that first 24 hours is stabilization and intensive care, fluid management, ensuring that organ perfusion and then wound management. Part of it might include surgery, that might be taking the patient to theatre for an evaluation of their wounds, scrubbing them, dressing them. It may involve urgent decompression, in other words, escrotomy, or it could even mean an early escrotomy, so full excision as well. There's two schools of thought about that and it's been summarized by a really big paper by John Greenwood, who used to work in adult aid burns unit. He said that we know that burn wins a dynamic, they evolve over those first 48 to 72 hours post injury and that the long-term goal is all about dermal preservation. That is the key to good squire quality, or more could say if that burns are exercised too early, then dermis that potentially could recover, in other words, that zone of stasis that we talk about in Jackson's burn wound model, which can recover with good resuscitation and good dressing care and adema control, so if we operate too early, then we can over to bribe the dermis. There might be bits that actually we did not need to remove, so that group of people would say that the only thing to do surgically early would be limb chester abdominal decompression and then take them back 48, 72 hours later, and the decompression can be done either surgically or you can do it enzymatically with an exuberant, you can bribe things or you can do an enzymatic escrotomy, and then the full excision would then begin once the wound is fully decayed. The wound will no longer be as dynamic, they will hypothetically not deepen further and then that zone of stasis is either said yes, I'm going to live on that, forget it, and the wound has progressed, but the other school of thought, something that we practice here in Newcastle is an early excision, the benefits of that approach are seen to be removing that full thickness escot early, so you're reducing the necrotic burden and also the surge response that is caused in part by all of the inflammatory cytokines which are leaching into the circulation from that tissue, you're excising them in the epphase of their burns, so when they're hypodynamic which mean that you can reduce blood loss, the longer that you leave that burnt skin on the more vascular it becomes, which makes surgery a lot more difficult and bloody, and certainly when we inherit patients from other services that are further down the line than we would normally operate, we find that the surgery is a lot more challenging and their postoperative recovery can be a lot more rocky. Removing all of that dead skin early within the first 24 hours also reduces the risk of infection, patients have less pain, they also have less restriction in the lymphins as well, which means that you can start physiotherapy earlier, so I think those again are two schools of thought that you should be thinking about for the exam, I think though it's very important to just say what you've seen during your training, so my trainees go to the exam and they say we would take this nation to this and we would excise it and they can back that up with the rationale and the evidence of why we do it, but equally if you're in a service that does an escrotomy and formally excises at 40 hours, that's fine, again it's just two different schools of thought and how to address the major burn injury, you just need to be able to back it up with your experience. Yeah and each with seemingly quite interesting rationale behind both of them say and like you say not entirely straightforward. No nutrition is also really important isn't it for these patients? When would you try and establish feeding? Yeah so nutrition is it's such a critical part, really from the get-go, you know there's a large volume of evidence that you get that early bacterial translocation from the gut, you get hyper perfusion of the gut, which means that patients become more systemically and well, so really the guidelines should be to cite an engine. men's feeding within six to 12 hours of a patient, sustaining a major burn injury. The practicalities of that, it's not always as straightforward. So again, if you're at a DGH and you're transferring someone a long way, it may not be achievable because there may not be, you know, dietician available, you may not have an out-of-hours protocol, but certainly here, NG's are cited as soon as the patient comes in and we have an out-of-hours feeding protocol so that they start enter all nutrition as soon as we can so that to maintain gut viability and ensure that they're starting to get some calories on board because of the massive catabolic response that these patients are going to have. And then that could be supplemented with other things to try and address that hypermetabolism through beta blockers or oxandrolone as well, but it is really important. When we prefer not to do TPN, it's very challenging to do TPN and burns patients. It's just very difficult thing. So if we can get them entry really fed early, then we're on to a winner, need to make sure that they're absorbing that feed. So it may be that you start very slow with the volumes that you're putting in. You're going to be doing regular aspirates or the NG to check their absorption. If you're getting high aspirates, then you consider putting in prognetic agents, metaclopromide or even they might need an NJ for post-pliorealoric feeding placed so that you don't have that issue. But yeah, it's one of those things that we really can't stress enough and I think it's important that that is brought up in an example situation that wants a patient is in an appropriate burn service, the entry on nutrition is started early to reduce the risk of complications. What is the role of adjunctive technology such as laser doppler or thermography? So laser doppler is the most widely used in the UK. It's non-invasive for those people who haven't seen it. It's designed to assess tissue perfusion or blood flow in burn injuries. So the principle is that you're shining a low power laser onto wounds, it scans it and then through the doppler effect, the light is reflected off red blood cells which are in the vessels, in the capillaries and the frequency of that reflected light then shifts. So just like if a police car goes past with the siren, it's the same kind of doppler reflected, shifting, it's reflecting back and then that's detected into the machine which generates a color coded perfusion map that visually represents blood flow in the tissue. It's most accurate between days two to five post burn so often that means that we'll perform that at 48 hours patient may be in for 48 hours before they can have a validated LDI scan and that can limit your decision making process and prolong the length of stay and it gives you your output say this wound will deal with in less than two weeks or two to three weeks or more than three weeks. So it helps support how a clinical decision making assertions to guide which areas need surgery. In all of the research though it's been shown to be up to 97% accurate compared to 70% that's paper by Sarah Pate that people should look at which can serve as a reference for their exam which talks about the application of LDI and how accurate it is. The new kid on the block at the moment which some people may have come across is the combination of multispectral imaging with artificial intelligence which is currently being trialled in a handful of UK burn centers and also Australia. So multispectral imaging it refers to shining multiple wave lengths from the visible and near infrared spectrum onto a wound and it means that you can get a very detailed analysis of tissue composition, oxygenation, hemoglobin and also water content. So it gives you information which the key indicators of burn severity, tissue viability and healing potential. There's a whole library of wounds that artificial intelligence can program the width and tissue biopsies and it correlates the multispectral signature with that wound library and processes it through a wound healing algorithm. So it gives you a very binary output you know I just said this wound will deal in less than three weeks or it won't heal and it's quite an exciting new technology and we're just waiting to see how it performs against LDI you know the company say that it has a wide evaluated window and that you can use this new technology from the same day that a patient gets burnt which means then that we can have much earlier decision making potentially operate on them earlier and reducing the length of say as well as letting patients know whether or not they need an operation. So I think that will form part of our approach to burn care in the future. It's not there yet, it's still very much in the early application phase but I think it represents a real avenue in the future for the application of AI in burns. That's really exciting that there's things like this on the horizon that hopefully will let you say transform further care for these patients that we look forward to that. We've mentioned briefly about children and I think you mentioned about the resuscitation thresholds are obviously different but what are the other key differences in managing a key burns in children as compared to adults. There are quite a few actually so from a skin point of view we know that children have thinner skin than adults and that means that there is a much higher likelihood that they will get deeper burns with either you know the same period of thermal exposure and adult or with less exposure you need lower heat for them to get a full thickness burn. They also have large surface area to volume ratio, they have big heads, shorter legs which means that they require more fluid and they're more prone to heat loss as well. So their fluid needs generally higher per kilogram and they're very prone to rapid decompensation leading to hypervalemic shock, fluid shifts and dehydration as well. Thinking again about fluid we need to think about the need for salt and sugar when we're resuscitating children so you have the Parkland formula but Parkland uses Hartman solution for children you need to supplement that with some maintenance fluids using point nine cell line of 5% dexterous to make sure that they have those on board as well. But just beyond what we are surgically doing they're also anatomical differences for the need to be aware of which can make it a lot more challenging smaller airways, higher risk of obstruction from a deemer as well. They have differentiated ediglottis, their larynx is high and anterior, they have a short trachea and their cry cord is very narrow and they may also have very large tonsils and adenoids which means that if you combine all of those together with an airway that is already inflamed from inhalation of hot gases or vapor that intubation can be extremely challenging in these kids as well. So other differences yes for the big burns we've already talked about feeding children have a higher basal metabolic rate so greater caloric and protein requirements for healing which means that we should be thinking about their nutritional input and nutritional support even earlier than an adult and have a low threshold for supplementary entry on nutrition if necessary. And then you need to be thinking more generally about the psychological developmental and psychosocial demands of a child. The trauma not only of the event and the long term risk of psychological impact but also that of their families I'm very much about when a child is admitted having an approach to accommodate not only their physical age but also their emotional in hospital, you know that thinking about repeated trips to theatre, painful dressing changes there really is a need for bespoke, burn care for children making sure that things are optimised on an individual basis for them. I guess that's where having that whole MDT representation as well is really important to get everyone involved and behind that you hear. Definitely. Definitely. But to support the whole thing from start to finish it to team abortion adults but it's even more so in children I think you need to be really collaborative and have support from pediatricians play specialists, the hospital school if you have one to facilitate these kids when they're in hospital. Yeah, absolutely. So what would be the ideal timing of surgery for these patients and what is your approach? So I think a lot of the decision making I make very early on, probably at the time when I see them in ED or when I see them on intensive care during the first couple of hours it's going to be dependent on the depth of the burn, the distribution. I assess people very early on when I see them in recess about their skin graft owner sites and thinking where am I going to get skin from to start putting this patient back together. Do I need to consider other things like dermal templates? Now, we're not on allegraft service but there would also be when it should be thought about. Also thinking surgically right, which bits am I going to need to reconstruct with sheet graft? What am I going to need? Mesh graft. Physiologically, how well is this patient and what is their temperature? What are the transfusion requirements going to be? So the general approach to any kind of major burn in the patient. Excision, you need to think about what your timeline is. So we've already talked about the immediate excision in the first 24 hours, and then early excision would be anywhere between 48 hours and five days. It's a late excision, so that would be where you allow the wound to declare itself and see how much we're here by secondary intention. See how I'd be grafting them anywhere between 10 days and three weeks, and then late grafting. So I'd do some work in Africa, and their wounds are allowed to granulate for late grafting, purely on the basis of very limited resources. So we've already touched on the benefits of immediate and early excision. So immediate excision, which I practice here for big cases, will be taken to the theatre within those first 24 hours, if they're anesthetically stable, because you have that anaesthetic window. In theory, they are as well as they're going to be when they first come in. They're in that eb phase, so they're hypodynamic to reduce their blood loss, and if we can offload all of that Esca early, then we should have a reduced resuscitation volume attenuate their search response, and if you were going to do it, not that we do, cultured epithelial autographed, you can take your samples at that window and send them away to Switzerland to go and grow you some skin grafts. The problem we're doing it in those first 24 hours is predominantly manpower. It's scary, taking a patient direct from recess to an operating theatre and sobriety in the middle of the night is uncomfortable for a lot of people, including myself. So it's all about having colleagues available, so you can phone a friend. There's also a significant risk of over-dubribing. We said about dermal preservation being the key to long-term scar quality. So if we go crazy in those first 24 hours and move too much, the long-term scar quality isn't going to be as good. There's also that risk of further wound progression if we don't exercise enough. And I wouldn't contemplate doing any early autographing at that first immediate excision. It's just not going to happen. So what about if we did it at that early window? So day two to five. Well, the wounds are fully declared. So in theory, you're not going to overexcise. You're going to just excise exactly as you want down to healthy pleading. A dermis or fat is also less risk to putting on autographs or templates as well, dermal templates. And they've had a period of ITU stabilization. So you've had 48 hours from the intensivists to get their fluids right, make sure that everything's working properly, correct any electrolyte or they come to theatre. But they're going to become a lot more surzy. They still have the escar on. They're just going to be having that inflammatory response. They will therefore be more blood loss because the tissues will be more vascular. And they will have been fluid shifts leading to dermal necrosis. So my preference, as I said, is about immediate excision depending on how stable they are. We will go direct from recess to theatre or they may go for a very short period of stabilization or intensive care for some warming and to put lines in. And then I'll take into theatre out of recess, which means that I can keep them warm, pre-warmed theatre, evaluate their wounds, and I can start scratching my head about how I'm going to put them back together, do they need any decompression? Are we going to use nexibrid? Am I going to do an S-correct immune excise at all? I always look to plan from one step ahead, looking at those donor sites for the first encounter. I'm planning the next procedure and the priorities of why I need to graft. A lot of people think that burn surgery is easy. It's just excising, putting skin grafts on casually. There's a lot of planning involved. And this is big trauma surgery. These patients are the sickest in the hospital. So you need to be confident in the team that you have around you when you're taking these big cases to theatre, which is why you should be working closely with concerned colleagues, resident doctors, so that you can do this quickly and safely to make sure that the patient has a good outcome. And so in terms of your surgical priorities for these patients when they come with potentially burns and come facing most of their bodies, what influences that from your point of view? I think it's very much influenced by the size and also the location of the burn and thinking about which anatomical areas you need to get good skin coverage over first. So key principles would be early deprivation of non-viable tissue, anatomical sites to protect. So if they've had the anterior neck burnt, they're a major burn. You need to divide that. You need to think, are they going to need a tracheostomy at some point in the near future? Therefore, the neck would serve as the priority for sheet grafting, thinking generally in that area, the eyes are the eyes protected. They're, again, critical that you get those covered involving ocular plastics if necessary. Linesites, so superclivicular foxy groins, a lot of them need early, intracurricular warming. They will need central lines. They're going to need big access for not only fluids, but for blood sampling, ionotropes, antibiotics, because of infection, so make sure that your linesites are grafted early. Another priority for me is hands. I like to graft hands as soon as I can to get them healed so that you can then start reintroducing physiotherapy. And another key area for me is pre-tibial. So if you've got very badly burnt legs, not to the point where they're non-thalvergible, but both it was burnt all over the legs. I like to get shins covered earlier, because if that progresses and you get tibial exposure, you're going to run into problems early. So, yeah, I think those are the key sites that I would want to shut down early. It's my approach now for big cases is excising them, grafting those key areas. And for the rest of the burn, I applied dermal template. The reason being is that I like patients to have their wounds sealed, I use BTM a lot. So BTM will shut the wound down, will mean that patients can physiologically improve until waste graft early, while the patient is on an intensive care and getting lots of iron tropes and their high risk. Yes, I would graft their hands and their neck early, but the rest of them I would BTM. And then when they're physiologically better, you can take them out of that holding pattern and start grafting them. I think it's been like a real game changer. Now, an alternative would be that patients have alligraft. Now, I'm not a user of alligraft. I'm probably in the minority, a lot, UK burn centers, as well as overseas use alligraft and it's an extremely important resource. So, when you're talking about the major, how to manage a major burn for the exam, be that alligraft BTM, whatever, talk about what you've used locally. So, again, my trainees will not go to the exam and talk that they use calyveric skin because they haven't seen it and we don't use it. They will talk about using synthetic dermal template to shut the wound down. So, talk about what you're used to and then you'll be able to back it up with the cases that you've been involved with. Absolutely. What is your approach to the patient with extensive burn and limited donor site availability? So, for me personally, any kind of burn that's above 30%, I would take direct theater. It means that it's a lot more controlled. I don't like people being, and their wounds exposed in a recess, I like to say them somewhere where it can be pre-wormed and then I could do a much better assessment than in a cold recess room. So, they can be scrubbed. We can do an S-correct to me. If necessary, we tend to use bibrone after we've excised to burn acutely because it will be hemostatic, it keeps the wound clean and then they return to intensive care for a period of stabilization. And if they remain stable, then our aim is to take them back to theatre 48 hours later. And then I'll start commencing, grafting and templating them. So, grafting the priority areas. So, neck in case of the need for a tracheostomy, periorbital skin, hands, feet, shins to avoid any tibal exposure and also the line sites. So, if they've got insufficient donor or I've done full thickness excision, or they're on lots of ionotropes, which is very common now, I will temporise the rest of them with BCM. Because in my opinion, it shuts down the wound very well. It attenuates that hypermetabolic response because the body isn't trying to heal itself. It's essentially sealed shut and plastic. It'll be analgesic for the patients. You can then start your physiotherapy early and you haven't sacrificed any of their donor sites and you're not gonna get any graft loss. Alternative to that would be alligraft, but I have no experience in using that. So, for my patients, they're then a holding pattern. We can wait then until their donors have healed or they're well enough to start grafting them and we're constantly looking ahead to the next operation and planning. I'm also very much a fan of autologous self suspension. So, resell, I'd like to use that on places which are burn, which have thick dermis. So, I will use resell on a back and any superficial partial thickness areas to expedite the healing. And therefore, the quicker that heals, the quicker I have available donor sites. I also take thin skin grafts so that their donors heal quicker. And we also do meat grafting. So, for those who haven't come across meat grafting, there are some great YouTube resources that you can see how it works, but essentially it breaks down skin grafts a special meek measure. into tiny little squares so that they're all separate from each other and then you can expand them to a predetermined ratio up to 1 to 9 and then place them on the wound so you get more bang for your buck with meat grafting and in my hands it's useful for big burns but other centers have a lot more experience and you're using it for small burns as well and I will combine meat grafting with me to resell and put that on to BTM and overall our aim is to keep them momentum going this so once you start grafting I'll try and get a couple of percent done each week rotating the donor sites reselling the donor sites to get them here real quick. I scheme graft on the back or buttocks until last because in my mind they're low priority until you've got patient who's compliant and can either lie on their front or on their side rather than just sitting on the back and it all she is and falls off and then it's just been a complete waste of time I also like to use nexobrid for faces and I know that certainly Yorkshire is at the forefront of nexobrid in the UK that's where we're following suit there we're learning from what the guys in Pindifilter during a terms of you're using it for faces and at the parts of the body. Fantastic thank you. What are the major complications to be mindful of in the acute management of a major burn? It's a it's a huge question it really depends on where we are in the timeline of that burn and their admission you can think that things like airway obstruction so superglotic airway injury from inhaled hot gases patients will often be dead at the scene or early on in their admission inhalation injury as well will be very quick so infrogotic injury they develop that chemical pneumonitis from inhaling all of the products of combustion and smoke which means that they will develop early chest infection and ARDS and also hypervalemic shock if it's delayed identification of a patient with a big burn or they don't get enough fluid transportation that that will occur early on the biggest risk for all of our patients is infection so you have open wounds they will remain prone to infection until you get their wounds closed as well as through the chest urine invasive lines that they have put in they are just going to be susceptible for the duration of their admission and then you have other things that you need to be looking at electrolyte imbalances or the risk of getting acute kidney injury during that early admission and resuscitation thinking long return you have the hypermetabolic response to address and that start early but can go on for months or even years after a burn wound how are you going to deal with that you know acutely enter a nutritionist critical beta blockers to try and attenuate their tachycardia and hypermetabolism and then using oxandrolone to anabolic steroids to try and counteract that and preserve lean body mass and then even further into the future you have the psychological trauma you know what were the circumstances that led to the burn injury how are you going to deal with that there's quite a lot of research particularly from Western Australia that shows that the effects of burn injuries are lifelong and it can impact your well certainly a child's propensity to develop many conditions and diseases in the future it changes almost who you are as a person after you've had such a big trauma like this and the after effects can be far reaching which I think are probably under recognized yeah some of that stuff I've seen some of it some of the BBA meetings being presented and there's some really interesting long-term data isn't they're looking at cardiovascular risk and inflammation and all sorts of different things as well as the things you might expect it's a really really interesting stuff there that I think we're only just probably starting to to really understand and I guess as you say there's a massive question because there's just so many of these complications but I guess that just underlines just how unwell these patients can be yeah like I said these patients can be the most unwell in the hospital and it really needs to a team effort not only from surgeons and surgical nursing staff but an ethos and dietitians and everyone else you know to get these people across the line and then it's hands off from me and it's the physiotherapist and OT's that are getting them back into society so it's a huge job these are then patients for life when I see these people coming in I just think I'm going to be reconstructing you for years to come you know or you're going to be having laser treatments these are people that you get to know intimately after they've had an accident these are patients you're going to be seeing until you retire and those longer term aspects of care that you talk about are also fascinating and it would be great we could do an entire other episode just on some of those things because there is so much there as you say with these patients lifelong management it's really very very interesting thank you very much to you mr. Lewis for joining us learnt lots there's really really interesting developments and things as well that I'm really excited to see what happens so thank you so much very welcome pub plus UK is a collaboration between UK and Irish plastic surgery trainees and consultants the content reflects individual's practice and opinions may vary if you have any feedback do get in touch we hope that this has been interesting and useful if it has remember to follow us for future