Okay, now there is the burn depth. The first degree is actually just a part of the epidermis, and just an epidermis. There is a second superficial part of the dermis, a second deep degree, it's actually also a part, but extensive, in the dermis. A third degree is reaching the hypodermis, and the fourth degree is actually reaching the vital organs. Now, we will talk about the burn center referral criteria. If there is a second degree burn, 10% for the surface, and the patients less than 10 or more than 15 years. Second degree, 20% PSA, other groups. Second degree and third degree with serious threat, so whether it is functional or cosmetic impairment, that involve also the face, hands, feet, genitalia, perineum, major joints. Third degree burns if more than 55% in any age group. Electrical burns, chemical burns, inhalational injury, circumferential burns with burn injury, burn injury with pre-existing medical disorder. Any burn with concomitant trauma, for example fractures. Also, if there is hospital without qualified personnel or equipment for the care of the children. Transfer to the burn center referral. Refer this for the burn center. There is also a sharatomy may be used of the full thickness burn. The full thickness burn can form a constricting burn that compresses the limb pervasion. During fluid resuscitation, the swelling increases. In general, sharatomy can be indicated for full thickness circumferential burns of the extremity, or for full thickness burn in the chest when sharatomy compresses thoracic cage, excruciating and thus ventilation of the patient. Sharatomy can be performed at the bedside using scalpel or electrocuttery. Side of the sharatomy where it must be longitudinal incisions, axial incisions, and in normal skin, into normal skin, from the scars to the normal skin and down to the subcutaneous fat. So, we detect its depth, its size, and its blends and type of incision. Also, we may use fasciatomy, usually done in high voltage electrical burn, because of deep muscle injury and internal edema, lead to an increased intracompartmental pressure, and in electrical vein like in internal edema. Fluid resuscitation, significant burn injury not only result in local injury, tissue injury, but also initiate a systemic response that impact nearly every organ system. The release of inflammatory mediators include histamine, prostaglandins, and cytokines, can lead to decreased cardiac output, decreased vascular permeability, and alteration of the cell membrane potentials. There is also a scheme about representations of junk zone burn model, zone of hyperemia, also there is zone of stasis, and there is zones of coagulation. Burn injury destroy the body barrier to evaporative fluid losses, and lead to decreased cellular permeability in areas of the burn. In addition, in cases of larger vein, more than 20%, there is systemic response to injury that lead to capillary leakage. Burn resuscitation must account not only for the loss of fluid at the site of injury, but also to the leak of the fluid throughout the body. We will use crystalloid fluid by the Parkland formula. It is still the most commonly used method for estimation of a fluid requirement. The preferred fluid in acute burn management is ringer lactate. And if the patient has acidosis, we prefer not to use ringer lactate and use the ringer. Sodium chloride is not used because there is a risk of inducing hyperchloramic acidosis. Parkland formula is by 4 cc per kg per percentage of TBSA. Total fluid to be administered in 24 hours. Half of the fluid should be given in first 8 hours. Half of the fluid also must be given in the next 16 hours. The fluid should be ringer lactate. The reason why it is important to give the first half of the fluid is due to the acute loss of the fluid. The fluid should be tightened to achieve urine output of 3 cc, 13 cc per hour and adult 1 cc per kg per hour. Therefore, a Foley catheter should be used to accurately track urine output. Colloids typically not used 12 hours to 24 hours following burn when cavernous leakage has started to seal. Fresh frozen plasma albumin is mostly uncritically active solution and does not carry a risk of disease repercussions. Topical wound agents that is may be following after the admission of the burn center. The patient's wounds are glistened with soap and water. Loose tissue and blisters are deprived. Body and facial hair are shaved if involved in the area of the burn. Daily wound care is preferred. Performed on shower table with soap and tap water. Burn injury destroys the body protective layer from environment and dressing are indeed needed to protect the body from infections and minimize evaporative heat loss from the body. Broflectic systemic antibiotics have no role in management of the burn wounds. In fact, the use of broflectic systemic antibiotics has been shown to increase the risk of opportunistic infection. Since burn issue has no microcirculation, there is no mechanism for the delivery of systemically administered antibiotics. Therefore, topical agents need to provide a broad spectrum antibacterial coverage of the site of colonization and the issues. We may be used also sulfur-sulfur diazine, methanide, sulfur mylon, silver nitrate also may be used to prevent bacteria. Inhalation injury is divided into supraglottic and subglottic injuries. Supraglottic is caused due to hot air to airway causing edema and obstruction. Supraglottic inhalation products of consumption composition can lead to devastating pulmonary injury and lead to chemical pneumonitis and secondary bacterial infection. Carbon monoxide poisoning caused by incomplete composition of the object in a closed room. Treating by 100% O2, carbon monoxide inhalation is potentially devastating since carbon monoxide will bind to hemoglobin and interfere with delivery of the oxygen. Diagnosis of inhalation injury is based made by consideration of circumstances surrounding the burn injury and findings on physical examination. The gold standard for diagnosis is bronchoscopy. Management of inhalation injury is supportive. Patients with signs and symptoms of inhalation injury may require intubation and general bath to secure patient airway early in the worst burn period.