SUMMARY. The objective of the work was to verify or rule out the hypothesis on the negative effect of incorrect prehospital and primary hospital care on the maturation of scars after thermal injuries with a depth of ll.b or more.In a medium-term study the authors investigated the maturation of scars in children aged 3 months to 12 years with different quality of treatment during lay first aid, during prehospital and primary hospital care. They focused attention in particular on the formation of hypertrophic scars and possibly other complications during the functional and aesthetic stabilisation of the scar.
Einfluss der mangelhaften vorarztlichen and primaren arztlichen Betreuung auf die Narbenreifung nach der thermischen Verletzung
Hamanova H., Broz L.
Dos Ziel dieser Studie was die Verifikation der Hypothese Ober negatives Einfluss der fehlerhaften vorarztlichen and primaren arztlichen Betreuung auf die Narbenreifung nach dem thermischen Verletzung (Verletzungstiefe ab der Store ll.b). Im Rahmen diner mittlefristigen Studie wurde die Narbenreifung bei der Gruppe der Kinder im Alter von 3 Monate cis 12 Jaher beurteilt. Diese Kindergruppe kennzeichnete sich durch die unterschiedliche Behandlungsqualitat im Rahmen der Ersten Hilfe and der vorarztlichen and primaren arztlichen Betreuung. Die Authors haben vornehmlich die Bildung der hypertrophischen Narben and eventuelle Komplikationen funktioneller and asthetischer Narbenstabilisierung untersuchn.
Key words: scar maturation, burns medicine, prehospital care, lay first aid, thermal injury, hypertrophic scar
The precise mechanisms of regulation of tissue healing and the cause of the formation of bypertrophic scars have not been completely elucidated so far (3, 5, 6, 7, 15). After thermal injuries the resulting functional and aesthetic character of the mature scar depends on general as well as local factors (3, 5, 6, 7, 15). General factors include the patient's race, sex and age, state of immunity, nutrition, longterm medication or abuse in adolescent or adult subjects, associated diseases, postoperative complications, mental unstableness or psychosocial factors. Local factors include the type and depth of the thermal injury, the site and mechanism of the affection, the frequency and time of surgical interventions at the site of the burn. In addition, there are subsequent complications of healing, the intensity of primary haemorrhage during the injury, contamination of the wound, inflammatory reactions (2, 3, 5, 6, 7, 10, 11, 12, 13, 14, 15), the period of action of fluid in the blister (17).
The objective of the medium-term study was to evaluate the quality of scar maturation after a thermal injury with a ILb or greater depth of the burnt areas in children aged 3 months to 12 years in conjunction with the quality of prehospital and hospital care. We investigated whether are significant differences exist between the functional and aesthetic quality of the scar (in particular as far as the formation of a hypertrophic scar is concerned) in children treated adequately during lay first aid, prehospital care and possibly primary hospital care and in children treated insufficiently or not at a11.
As a basis we used findings which indicate a direct relationship (4, 8). We wanted to verify or rule out in our study this relationship, which is of great importance for us.
In the submitted medium-term study (Jan. 1, 1998-Aug. 1, 2001) we investigated healing of burnt areas in children aged 3 months to 12 years, mean age ca. 6 years, where the depth of the affection was classified as ll.b or deeper. This was a group of 180 children: 72 girls (40%) and 108 boys (60%). The tested group was obtained by random selection as the children were referred by the attending surgeon for follow-up care to the Outpatients Department of the Rehabilitation Clinic, Faculty Hospital Hradec Kralove.
The thermal injury was most frequently caused by scalding, in the case of 139 children, i.e. 77%. Boiling water, coffee, tea, soup and other fatty liquids were involved. This type of injury was recorded in particular in the lower age groups. In 22 patients (12%) burns by fire were involved, in 14 patients (8%) contact injuries. Injury by electric current was recorded in 5 children (3%), chemical burns were not treated during the investigation period mentioned.
In all patients several sites were affected. The most frequent combination were burns of the face, chest and upper extremities, or chest, abdomen and lower extremities. Burns under 5% BSA were recorded in 86 children (48%), under 10% BSA in 54 patients (30%), under 15% BSA in 29 children (16%) and above 20% BSA in 11 children (6%).
In the study proper we investigated the sear maturation from healing of the wound, i.e. from discharge of the patient from the surgical outpatients department or hospital, to complete functional and aesthetic stabilisation of the scar. Check-up examinations were made regularly depending on the local status - most frequently once a month, in case of complications more frequently. We focused attention on the development of a hypertrophic scar or keloid and other complications of healing - aesthetic or functional (e.g. contractures, hyper- or hypopigmentation etc.). The scars were documented during treatment by photographs, planimetrically and a US probe (8). For evaluation we subsequently used the Vancouver score (16).
We classified care as "sufficient" according to lege artis standardised procedures. The group of patients with "insufficient care" was divided into those not treated and patients who had care not consistent with lege artis standard procedures, or those with late treatment.
Lay first aid
Information of the quality of lay first aid was obtained from a questionnaire addressed to the parents or from records. Of 180 patients adequate treatment was provided to 46°/ (83), 38% children had inadequate treatment (68) and 10% patients (18) had no prehospital lay treatment. In 11 children (6%) we were unable to assess from anamnestic data the quality of lay first aid.
Lay first aid is differentiated into high quality and insufficient care
First medical aid - outpatient or hospital
Rather inadequate treatment was recorded in more than half the patients, since in 94 children (52%) the first medical aid was provided at the Department of Paediatric Surgery in the Faculty Hospital Hradec Kralove. 86 children (48%) were referred by departments from the catchment area after primary out-patient or hospital treatment. Of this group 33 patients (38.4%) received inadequate treatment! We consider this finding alarming. The more severe the affection, the poorer the quality of care provided in the catchment area.
Dependence of formation of hypertrophic scar on inadequate or incorrect lay first aid
In 73 patients (84.970) from the group with inadequate lay first aid or without treatment the first signs of pathological scarring were diagnosed very soon, as well as the formation of functionally and aesthetically inacceptable hypertophic bulges and incipient contractures.
Hypertrophic scars were detected at the site of the primary burn as well as in the area of collection of autografts and transplanted areas. The total therapeutic period of the thermal injury was protracted, as was the period before functional and aesthetic stabilisation of the scars was achieved (by at least 6 months). Hypertrophic scars were objectively expressed by the abovementioned methods of documentation. Treatment was implemented by standard procedures depending on the state and site of the scar, the child's age, tolerance of therapeutic methods and financial status of the parents up to the functional and aesthetic stabilisation of areas.
Dependence of formation of hypertrophic scar on inadequate or incorrect ambulatory or primary hospital care
In 31 patients (almost 94%!) from a group of 33 children with inadequate ambulatory or primary hospital care, pathological maturation of the scars was confirmed as early as the first examinations. Hypertrophic bulges were assessed objectively by the abovementioned methods. We also recorded increased painfulness of the scars and a significant retardation of the tissue reaction to adequate therapy - always at least by 6 months. Moreover, in patients we found a higher incidence of hyper- and hypopigmentation of scars. Children in this group tolerated the checkup examination poorly, i.e. personal contact with the doctor (frequently in a very restless child it was difficult to examine the scars by palpation) and the children accepted to a minimal extent all available therapeutic methods of the insufficient cicatricial tissue. During treatment various complications developed, e.g. allergic local reactions, intolerance of local remedies and aids for pressure therapy of scars, intolerance of pressure massage of the scar, eczema of the affected areas, fissures. We also verified indirectly that it is quite justifiable to include a serious thermal injury among psychosomatic affections (1, 2, 10, 11, 12, 13, 14).
Hypertrophic cicatrisation was diagnosed again at the site of the burn as well as at the site of the skin graft and the site where it was taken.
Documentation of hypertrophic scars, complications of healing and subsequent therapy of the affected areas was identical as in the previous group.
The investigation confirmed the hypothesis of a direct association between adequate lay first aid, prehospital care and primary hospital care after a thermal injury and the later formation of a satisfactory skin cover without pathological hypertrophic cicatrisation.
Mistakes in lay first aid, prehospital and primary hospital care not only lead to the rapid development of complaints associated with manifestations of the psychosomatic affection of the patient (1, 2, 10, 11, 12, 13, 14, 15), but also protract significantly the treatment of thermal injuries, as mentioned for example by Costa or Judre (4, 8). Impaired functional and aesthetic stabilisation of the scar is more frequent (i.e. hypertrophic scars are formed) as well as other complications of healing (e.g. the formation of contractures, hyperor hypopigmentation of the affected areas). This direct and very serious association was proved in a medium- term study in child patients with a Ilb or deeper burns. Also Clark, Ellitsgaard, Ferguson, Hurren, Konigovd, Linares and others draw attention to the importance of prevention of thermal injuries and the necessity to provide adequate prehospital and primary hospital care.
The crucial problem remains:
Although prevention of thermal injuries remains the crucial question, it is important to improve the knowledge of the lay public on methods of first aid in thermal injuries. The basic problem still remains the necessity to improve care provided in the first contact. This applies to surgical outpatients departments as well as hospitals in catchment areas. It is necessary to eliminate mistakes made by physicians when indicating transport of the child into a specialised centre for burns medicine or a department which is able to ensure adequate care. We cannot tolerate mistakes as regards safety of the patient during transport to a higher grade department.
Our study confirmed the direct relationship between the development of a hypertrophic scar after thermal injuries and the quality of lay first aid, prehospital or primary hospital care in children with Ilb or deeper burns, which we classify with regard to their character as psychosomatic affections. The resulting therapeutic effect is evaluated from not only the functional but also the aesthetic aspect (1, 2, 10, 11, 12, 13, 14).
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