Case History of Laser Therapy of Extensive Burns and After-Burn Scars

 

Mr. and Mrs. Hintenaus, Dobroutov, CZ,

Mr. Pavel Malek, M. D., REHAB CENTRUM, Jihlava, CZ,

Mr. Jan Koupil, M. D., Clinic for Burns and Reconstructive Surgery, Faculty Hospital Brno, CZ,

Mr. Premysl Fryda, MediCom a.s. Laser, Prague, CZ

 

Abstract

Unusual case history describing a long term treatment of extensive burns and after-burn scars with the use of LLLT on a baby patient.

 

The Parents

Their story started on 21st of September, 2000. Following mother`s two-months hospitalization, Claire was born before midnight. After three days, in the course of a routine check of the new-born baby, the hands of a nurse caught fire inside the incubator. The device was immediately in flames and so was its precious living contents. Fortunately, the resourceful nurse managed to take the baby out. However, despite of this, Claire sustained extensive burns on more than on one fourth of her body, and the fight for her life began. The doctor in charge as well as the entire medical staff managed to cool and treat the involved areas in the shortest possible time, including stabilization of vital functions. Claire had then been rushed to the Burns Center in Brno and handed over to the Intensive Care Unit of the Neonatal Department of Brno Faculty Hospital.

"When they came at night to tell me that there had been a misfortune, my reaction reflected the condition after a complicated pregnancy and a childbirth. I was confused and the only thing that struck me at the moment was - why just me? However, we have never admitted that it could not turn out well," says Claire`s mother today. The incident of a burnig incubator and a burnt baby girl had shocked both medical and general public. Numerous clinics using same devices all over the country have been waiting for the outcome of the investigation till now. Investigation was complicated also by the fact that the course of the incident cannot be reconstructed... Presumably, the cause was a discharge of static electicity on the hands of the nurse. However, any speculation about the fault of the medical staff is rejected by Claire`s dad: "When you see your own child wrapped from head to toe in dressings, connected by various tubes to machines supporting basic vital functions during forced sleep, the only thing you can do is to beg her in spirit to fight for her life, not to surrender. The life is worth it. According to burns experts even five per cent is critical for such a baby. Claire survived five times larger extent than that! She was strong enought to fight for her life, and she won. Apart from all the efforts taken by the doctors and medical staff, it was also thanks to her strong constitution"

Though her parents did not surrender, too. The week following the accident they both spent in the hospital with their baby. Together they overcame the most critical period, hoping that everything will turn out well. After ten days doctors started to ablate damaged skin, transplanting gradually healthy skin from other parts of the body. After another week Claire was disconnected from devices and her mother came back to the hospital in order to be able to milk the baby and to learn how to treat healing wounds. On 20th of October, less than a month after the incident, Claire was discharged from the hospital. At home, apart from common care for several weeks old suckling, the parents started massaging scars intensively several times a day, this care being usually accompanied by Caire`s loud disapproval. Waking up at five in the morning every day, massaging the baby and 20 kilometers by car to Jihlava for rehabilitation and laser therapy. Once a week also traveling 90 kilometers to Brno for check ups, expecting the results to come only after a longer time.

And how about the result? Scars after burns and transplantations are healing up successfully. Furthermore, regular laser irradiations and mechanical massages suited Claire very well, and according to her parents Claire might even be smarter than other babies of her age. After two months Claire`s parents asked the doctor, who had been on duty at the newborns department that unfortunate night, to become Claire`s godmother. Action of the team under her leadership helped Claire to come back from the death`s door. "Even today, speaking about it makes me shiver down my spine," the doctor admits. Sometimes it is very hard to determine borderline between professional and private live. Definitely, the christening is a better thing to remember for her: "The girl is beatiful. I am happy it turned out well this way."

 

Picture 1: October 15, 2000, Condition before discharged from hospital

Out-patients rehabilitation specialist

Tha patient was born on 21st September, 2000, when pregnancy was terminated in the 36th week of pregnancy by a Caesarian section. Before delivery mother had been hospitalized due to cervicouterinal insufficiency. The patient is born immature - 2850 grs. / 47 cms. - thus embedded in an incubator due to breath complications, transitoral hypoglycaemia, and newborns jaundice. On September 25th, at 00.50 the incubator ignited causing II - IV grade burns of the baby in the extent of about 20 per cent. Following sterile cover and overall therapy (sedation and infusion) the patient was moved in an ambulance to a specialized burns center. Patient`s finding described multiple combustiones II grade on 2 per cent of the body (healed up conservatively) and III - IV grade burns on 18 per cent of the surface of the body, where there was in two phases performed chemical necrectomy with subsequent autotransplantation with a medium-thick D-E graft in 1:1.5 ratio. Implants adhered in full extent, transplant source areas healed up well, too. Mother was trained in nursing care and they both were discharged on the 26th day for home care (weight 3310 grs.). The patient was taken over in dispensary of out-patients children`s burns department.  

Henceforth pressure massages were carried on 3 times a day at home (30 minutes back, 30 minutes hand - by turns with application of Contratubex or Hiruroid ointments), together with laser therapy (LLLT) with a superficial scanner 670nm/25mW, dosage 2.6 J/cm² for 20 minutes on the most affected areas, i.e. an area of about 12.5 x 4 centimeters on the back and the left upper limb. LLLT daily for 6 months. Apart from that, irradiation with an IR laser probe 830nm/30mW, dose of 3 J/cm², applied on several localities (especially on a spot on the left elbow, the left thigh, the left wrist, and fingers 3, 4, and 5 on the left hand).

According to finding of November 15, 2000, scarry surfaces inflexible, slightly over the level, hyperaemic, deformities on the left little finger. Finding of November 29 - hypertrophic cicatrices on the trunk and left forearm gradually maturing, the course seems favourable. Only the condition of the area of left wrist and left little finger unfavourable due to gradual luxations of metacarpophalangeal and distal interphalangeal joints caused by contracting hyperfrophic scars. According to our finding the main progress can be noticed on the back where especially the peripheral parts significantly improved. Minimum effect noticed on the most affected fingers of the left hand, especially the little finger.

From January 9, 2001, laser Maestro with an infrared LineScan scanner 830nm/200mW was lent to carry on with LLLT at home. Therapy performed for 20 minutes on the back, dosage 2 J/cm², output power decreased to 100 mW, identical dosage on the left hand, time 13 minutes and 20 seconds. Furthermore, a supplementary dosage on the most affected fingers of the left hand (area 3 cm², dosage 3 J/cm², output 200 mW, time 1 minute and 30 seconds). In addition to that, superficial irradiation with a pinpoint laser probe 670nm/10mW, dosage 2 J/cm². This therapy performed daily including weekends till February 14, 2001, other therapies, i.e. press massages and ointments, unchanged.

Finding of a specialized clinic as of January 10, 2001, mentioned improved condition, scarry areas gradually softening, contraction of left little finger remaining. Finding of February 7, 2001, identical, hypertrophic scars on lateral side of the left forearm slightly less hyperaemic. Finding on the little finger the same. From February 15, 2001, LLLT substituted by phototherapy with Biolamp, irradiation 3 times a day for 20 minutes. After 4 weeks LLLT introduced again for the period of 2 months, IR laser probe 830nm/40mW, dosage 3 J/cm² every day, pinpoint irradiation of the forearm on 2 spots, 10 points on the wrist and fingers, 6 points of irradiation on the back.

Overall evaluation of efficacy on November 22, 2001, i.e. after roughly 14 months, states significant improvement of the condition, especially on the back. There is an area of about 2 x 6 centimeters remaining inflexible and latticed after above mentioned plastic surgery, presumably with the prospect of a rather extensive excision being necessary in this terrain. Furthermore, a significant improvement especially on the left forearm, left thigh and on dorsal side of the wrist. Unfavourable situation is remaining in the area of the left little finger, but there has probably been a severe trophic defect after a IV. grade burn, hitting deep structures including bones and not yet fully developed joints. Gradually a severe contracture of little finger developed, and thus it had to be resolved by an amputation on April 4, 2002.

On the basis of above mentioned findings it is possible to imply quite clearly that the most significant improvement had taken place during the first two months of application of LLLT. The condition was improving further on, but not so distinctly as at the beginning. In general, it is possible to regard LLLT highly successful, but the imporance of its early introduction should be stressed once more.

Picture 2: The scars after a series of laser irradiation - 4 months after injury

Specialized burns clinic

A rare clinical case. A new-born baby girl suffered 72 hours after the birth (Sectio Caesarea) a thermal injury when an incubator caught fire due to not yet revealed circumstances. Total area of burnt skin was 18 per cent  III. grade burns and 2 per cent II. grade burns. The newborn had been treated by a team of experts of the Faculty Hospital Brno (a neonatologist, an anaesthesiologist, a plastic surgeon, a physiotherapist) in the Newborn Department of the II. Children`s Clinic.

With regard to the extent and depth of the burns the newborn was artificially ventilated. The patient was resuscitated with crystalloid as well as by colloid suspensions, continuous antalgic sedative care, heparinization, substitution of antitrombine III, enteral and parenteral nutrition, immunity support by gamaglobulines and targeted medication by antibiotics according to results of microbiologic findings. Having stabilized the condition from the sixth day on, the team started a phased chemical necrectomy of the burnt areas as well as covering of the defects with artificial teguments. On the twelfth day after the injury we carried out autotransplantation with a thin dermoepidermal implant, ablated from both the thighs, right gluteus, and from the back. In the course of hospitalization no serious complications had occured, and 24 days after the injury with the burnt areas having been healed up the child was discharged for home care. 

From day 32 application of LLLT started. The patient was visiting our clinic for regular check ups when her condition was evaluated with special regard to prevention against hypertrophic scars formation. Adequate therapy and rehabilitation exercise had been recommended. The first series of LLLT was completed 4 months after the injury. After following series of LLLT skin hyperpigmentation gradually discolored. The color of the skin was getting close to standard color, and the scars were flattening. Despite all efforts (combination of biostimulation and biophysical rehabilitation techniques) we still were not able to influence substantially deformities and contractures of scars on ulnar side of the little finger.  

Thanks to excellent results in scar management in patients after a thermal trauma LLLT has became a common part of prevention against hypertrophic scars. It also helps to heal up chronic wounds. This therapy has best results when applied on firm palpable scars, red in color and profusely vascularized. Excellent clinical results have been corroborating a positive effect of therapeutic laser on hypertrophic after-burn scars.  

Picture 3: Condition 1 year after the injury

 

Laser manufacturer

From time to time you may happen to read in your newspapers an article hitting you much more than all the others do. However, with a little bit of sarcasm you can say that nespapers are all shocking news today, but anyway, something really can knock you back, that`s the way it is. And this was just the case of a burning premature baby girl in an incubator. In an incubator which should originally have kept the baby alive, but despite of this, oxygen flowing into the device on and on kept the baby burning.

Therapeutic laser means a significant support for a weakened organism, especially in terms of speeding up wounds healing, local diminishment of pain, and general biostimulation of body structures. In this particular case laser could stimulate healing of wound areas after autotransplantation, speed up integration of transplants, and especially help in post-operative rehabilitation of scars in order to soften and discolor them. Furthermore, there was a real risk of formation of keloid scars which would possibly block mobility or cause other problems in the future.

Soon we had found out that the burns clinic had had a laser available, and also the rehabilitation centre, which took over post operative care of the girl, was equipped with a laser scanner. Should this not be the case, we were ready to offer a long-term loan of a laser, just like we had done it in the past, for example in the case of a little schoolboy who had been poured over with an inflammable liquid and burnt by his schoolfellows, suffering burns on his hand and neck, or a woman who had been bitten in the face by a dog, or an ice hockey player who had had his cheek cut by a rival player`s skate blade, and so like. However, we could not help in this case, so we only gave an occassional call to the doctor, just to ask how therapy proceeds.

About a month later we were contacted by the father of the girl. It was early December, wintertime. He tried to explain that they were living in the Highlands, having to go by car every day more than 20 kilometers (on a road which sometimes gets negotiable by car very hard, as it happens from time to time during the winter in the countryside ...) to the town for laser therapy. This meant waking up at 5 o`clock in the morning every day, then to carry on with massages of the baby, see their two other children off to school, and then go by car for laser therapy, regardless to how the weather looks like. He asked us whether we could lend them a laser to proceed in the therapy at home. However, this was what we could not do, since working with a laser is subject to strict hygienic and security rules and, furthermore, the legislation does not allow us to distribute high-performance professional lasers to uninitiated public. At the end there was a possibility how to manage the situation thanks to human sympathy and understanding. The parents attended a laser medical training course, district hygienist officer inspected the house approving a "laser workplace" in one of the bedrooms, setting up binding rules for operating the laser. A laser scanner was installed, the parents being trained in how to operate the device. The parents closely cooperated with the doctor. This temporary and quite extraordinary solution could contribute to a quicker rehabilitation of the little patient, helping the whole family to overcome a dramatic epizode. Good luck, Claire!