Clinical Burn Treatment with Silver Nitrate

TABLE OF CONTENTS

ABBREVIATIONS

LIST OF TABLES AND FIGURES

INTRODUCTION

CHAPTER I
1.1. Background
1.2. Burns
1.3. Patophysiologic procesess of burns
1.4. Classification of burns
1.6. Open and closed methods
1.7. Local burn treatment with Dermazin cream
1.9. Early surgical treatment of burns
1.10. Local burn treatment with silver nitrate
1.10.1. Nikolsky-Batman method
1.10.2. Closed method with Silver Nitrate
1.10.3. Silver nitrate pharmacodynamics
1.10.4. Disadvantages of burn treatment with silver nitrate

CHAPTER II
2.1. Motivation
2.2. Research questions and methods
2.2.1 Research Question
2.2.2 Methodology of research
2.2.3 Research prosess
2.2.4 Methods of statistical processing
2.3 Results from experimental research
2.3.1 Experiments of applying of silver nitrate onto human skin
2.3.2 Method of silver nitrate application in the burn treatment
2.3.3 Statistical study
2.3.4 Effectiveness of clinical picture of the burn treatment with Silver nitrate

CONCLUSION

REFERENCES

Appendix

Case I

Case II

Case III

ABBREVIATIONS

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LIST OF TABLES AND FIGURES

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INTRODUCTION

The topic of the thesis is clinical burn treatment with silver nitrate, so called Nikolsky-Batman method. I wanted to make my residency in plastic surgery long time ago, I entered medical school, that’s why I choose topic of my thesis in this field. This work is done in Arad County Clinical Hospital in Romania in plastic surgery ward, other part in burn centre in University hospital of Helsinki in Finland the last part was in Institute Hospital Vishnevskogo, Russian State Academy in Moscow. The goal is to compare Modern European burn healing practice with Russian methods as well as with Post Soviet Europe practice.

After high school in my hometown St. Petersburg I began my studies in 1 Medical College in Sankt-Petersburg, then in end of 90-ties I moved to Finland, where I continued my education in Pirkanmaan Politechnic and graduated as Bachelor of Nursing Science, right after I entered Tampere University Russian translation Program, after a couple of years of study I graduated as Bachelor and Master of Arts. Then I got MBA-degree from Kokkola’s University of Applied Science Centria. This is shortcut from my background.

This topic belong to plastic surgery, which is my favourite field from whole medicine. I choose this topic, because I want to make my research about useful topic, the data I got can be implicated in daily practice and safe people lives or help in recovery process. Nowadays there is a lot of ways to treat burns, some of them are more comfortable to patient, some of them give better results in timing of healing, there are many factors, when surgeon choose type of treatment. In this work, I would like to concentrate on local burn treatment with silver nitrate. This method is investigated during World War II and it was used with great success direct after the war. Unfortunately, later with years with “help” of pharmaceutical companies new methods where implemented in burn local treatment and silver nitrate application where not more in use.

In this work we want to compare local burn treatment with silver nitrate and modern types of treatment. The aim is to find out the most effective, painless and cost-saving treatment in local burn treatment.

To explore this topic, it is needed to study theoretical issues in this field. The main study fields are the pointed basics of local burn treatment. We will compare Modern European, Russian and Post-Soviet Europe literature.

Thus, the first chapter of this thesis will be dedicated to the background of this research. First will be studied burns ethology in general. Then I will explore types of burns classification to see which type is suitable to local burn treatment. At the end of this chapter we will go through local burn treatment. I will study types of local burn treatment, later on I will describe each local burn treatment and its benefits. Then I will take a look for early surgical treatments of burns. I will go through types of early surgical treatment. Then I will take a look for suitable burns for early surgical treatment. Finally, I will concentrate on local burn treatment with silver nitrate. I will describe procedure, indications and contraindications.

The second chapter is a practical one. In it first part I will concentrate on methodology. Chapter will be used to state research questions and methods. I am go through on steps of my research. Upon the data about burns and burn treatment studied in the theory part I create a study plan for clinical research. Further I will concentrate on Silver Nitrate treatment and the results achieved. Then I will take a look on local and early surgical treatment in Plastic and Reconstructive Surgery Department of Arad County Clinical Hospital, to find out benefits of Nikolsky-Batman method used in this hospital. Then I will choose the patients with burns for Silver Nitrate treatment. Number of patients will be about 100 it is not very huge amount, but taking in consideration, that there are not so many burns cases available and not all burns are suitable for this treatment.

In the second part of second chapter I will present results of the clinical research. We will follow up the burn patients treated with Nikolsky-Batman method in Plastic and Reconstructive Surgery Department of Arad County Clinical Hospital. We will compare above mentioned treatment with other more popular types of local burn treatment.

The aim of this study is to find and analyse theoretical material about local burn treatment, and early surgical treatment. I want to focus in local burn treatment with Silver Nitrate, to find out how this treatment is up to date and is it applicable to modern medicine standards. By studying the best practices, I need to find out which local or early surgical treatment has the most better healing rate and less painful for the patient.

The research question in this thesis is to find out benefits and contraindications of local burn treatment with Silver Nitrate. Does this treatment suits to modern medicine standards and is it cost efficient? Is it pleasant and painful for the patient? Does patient remain with scars or psychical problems.

THEORY PART

CHAPTER I

1.1. Background

Burns included in plastic surgery field. Patient with burn injury can be treated in any hospital but severe cases as well as children need to be transferred to burning center, there are also special criteria to follow, who need transfer. Burn is injury of skin, which protect us from infection or other outside dangerous agents.

Thus, in this chapter I am going to investigate burns. Then I will take a short look at the burns classification. Then I will find out about local burn treatment. I will study types of local burn treatment, later on I will describe each local burn treatment and its benefits. Then I will take a look for early surgical treatments of burns. I will go through types of early sur-gical treatment. Then I will take a look for suitable burns for early surgical treatment. Finally, I will concentrate on local burn treatment with silver nitrate.

1.2. Burns

Burn is injury of skin and it is caused by heat, chemicals, cold, friction, radiation or electricity. Most frequent burns are caused by heat from hot liquids, fire or solids. Strong factor is smoking or alcoholism. Pathophysiology of burns represent protein braking down and losing their three-dimensional shape by temperature greater than 44°C. As the result is cell and tissue damage. This follow secondary effects, because of disruption in normal functioning of the skin. Such as normal body temperature regulation, skin sensation or ability to prevent water loss through evaporation. Lose of potassium to the spaces outside of the cell is because of disruption of cell membranes, also disturbance occurs in in taking up water and sodium. (Tintinalli et al., 2010).

Large burns, if they are more than 30% have inflammatory response. The result is subsequent edema of tissue because of increased leakage of fluid from the capillaries. This causes overall blood volume loss, with significant plasma loss, making the blood more concentrated. Poor blood flow to organs such as the kidneys and gastrointestinal tract may result in renal failure and stomach ulcers. Increased levels of catecholamines and cortisol can cause a hypermetabolic state that can last for years. This is associated with increased cardiac output, metabolism, a fast heart rate, and poor immune function. (Rojas et al., 2012)

Diagnosis is done upon physical examination. Main criteria to determine is depth of the burn, sometimes it is difficult to measure it, so examination should be repeated after some days. Classification of burns is subject for the next chapter.

1.3. Patophysiologic procesess of burns

In the pathogenesis of severe thermal lesions, an important role is played by reparative processes in the burn wound (Alekseev et al., 2008). Matveev et al. (2013) consider that the course of regenerative processes in wounds is significantly influenced by the products of decay of tissue necrosis and the vital activity of the bacterial flora that are extracted into the vascular bed during acute burn toxemia.

According to Vashetko et al (2006), with severe thermal trauma to organs and tissues, there are three damaging factors: hypoxia; biologically active substances and cytokines; products of metabolism and decay of necrotic tissues, as a result of which severe morphofunctional changes develop in them. This opinion is shared by Ostrovsky with co-workers (2006) and Polutova with co-workers (2011), who note that after removal of the patient from a burn shock, the resorption of fluid from the lesion begins, along with which a large number of toxic substances enter the vascular bed, which leads to the development of hemolysis of erythrocytes and hemic hypoxia. Cellular changes caused by the direct action of the thermal factor form the first stage of a complex inflammatory process – the primary alteration.

Data obtained by Paramonov with co-workers (2000) indicate that numerous biologically active substances participate in the pathogenesis of developing local disorders: activated oxygen species, products of lipid peroxidation, decay of proteins, fats and carbohydrates, inflammatory mediators, proteolytic enzymes, factors of the calicrein-kinin system, coagulation systems of blood . Pathological changes on the part of hemopoiesis are multidirectional and lead to deep microcirculation disorders (Lychev, 1993), which in turn entails dysfunction of vital organs (Presnyakova et al., 2005), which contribute to exacerbation of intoxication, the formation of a microcirculatory barrier around the necrosis zones of the burn wound, reducing the penetration of medicinal products into it. Disturbances of homeostasis that develop in the first hours after severe thermal trauma determine the pathogenesis of its acute periods (Milnera et al., 2010). As a result of pronounced disorders of peripheral circulation, oxygen transport to tissues is reduced. This contributes to the disruption of oxidative phosphorylation processes and the accumulation of under-oxidized metabolic products with the development of metabolic acidosis (Krylov et al., 2013). Hypoxia and primary alteration products initiate the development of secondary alteration (Serov et al., 1995).

Mediators of inflammation that are formed during primary and secondary alteration trigger the next link of pathogenesis – the stage of exudation, the pathogenetic basis of which constitutes a violation of the permeability of the vascular wall and the microcirculation disorder. According Pakhomova (1997), Smorodinova (2005), regenerative potential in the zone of thermal trauma largely depends on pathological changes in the microcirculation system and subsequent violations of transcapillary exchange. Both superficial and deep burns, despite the diversity of etiological factors and triggers of pathology development, are characterized by a stereotyped complex of morphofunctional changes in the area of trauma (Chesnokova et al., 2010).

Research M.K. Robson et al. (1990) show that the response of a cell to thermal exposure is not standardized and is determined by the blood supply and localization of the lesion site. The depth of tissue damage depends on the temperature and duration of action of the thermal agent. The degree of lesion decreases in the direction from the surface of the skin to its deeper layers and from the center of the burn to the peripheral areas. Around the central area coagulation, the so-called primary alteration zone, there is a zone of paranecrosis – affected, but still viable tissue. The zone of paranecrosis corresponds to the manifestations of ischemia, arterial hyperemia and stasis vascular reactions. For the first time, the process of acute inflammation developing after a burn was described by Cohnheim (1889), and on the basis of continued studies by Sevitt (1957, 1979) concluded that inflammatory processes contribute to the progressive destruction of tissues as a result of negative effects on microcirculatory processes in the field burn wound.

1.4. Classification of burns

Most common burn classification are made by depth of the burns. The size of a burn is measured as a percentage of total body surface area affected by partial thickness or full thickness burns. There are a number of methods to determine the total body surface area, including the Wallace rule of nines, Lund and Browder chart, or estimations based on a person’s palm size. More accurate estimates can be made using Lund and Browder charts, which take into account the different proportions of body parts in adults and children. The size of a person’s handprint(rule of “palm”) is approximately 1% of their total body surface area(TBSA). (Tintinalli et al., 2010)

Burn classification have a great clinical significance. Because upon type of the burn we chose proper care and treatment. Let’s take a look on classification step by step. First degree is superficial it involves epidermis, it appears with redness without blisters, also it is dry. It is painful and healed in 5-10 days. Prognosis: heals well, but can be cause of skin cancer later on.

There are two kind of burns in second degree A and B, lets take a look for A, in it superficial partial thickness is affected. Redness with clear blister occur, wound is moist and very painful. It heals in 2-3 weeks. In prognosis, local infection(cellulitis) may occur, but normally without scars. B type of second degree is when deep partial thickness is affected. This type extends into deep dermis, the color is yellow or white, less blanching, but maybe blistering. Wound is fairly dry. Patient feel pressure and discomfort. Healing process takes 3-8 weeks. Complications are scaring and contractures.

The third type embrace full thickness, it extends through entire dermis. It is stiff and white or brown without blanching. The texture of this wound is leathery. There is no pain, healing takes months and its incomplete. Complications are scarring, contractures and amputation, anyway early excision is recommended. The last is forth degree burn, it extends through entire skin, and into underlying fat, muscle and bone. It has black color charred with eschar, with dry surface, without sensation or pain. It requires excision. Its complication: amputation, significant functional impairment and even death. (Tintinalli et al., 2010)

Here it is studied the burns and their classification in general. Each type of burns is defined. The measure of burs usually define by depth, sometimes it cannot be seen at the first examination, so it should be exanimated on the next visit for final diagnosis. Size of the wounds is made by determination of TBSA. This information will helpful in conducting clinical research in hospital. Burn types define type of the treatment in future, that’s why it’s important to know them.

1.5. Local burn treatments, general issues

Main methods of local burn treatment are open, closed and coagulation. Open is without bandage and closed is with use of the compress. In our days closed method is more useful.

Local burn management starts with burn stage evaluation, upon it healthcare unit or outpatient care choose. In case of relocation of the patient first aid should be done and wounds properly dressed. There are different recommendations which local antimicrobial agent should be used, anyway it is usually used in bigger burns. Cleansing and debridement is done by burn blisters. Topical antimicrobial agents are: Silver sulfadiazine, Combination antibiotics, Chlorhexidine, Mafenide acetate, Providone-iodine ointment, Bismuth-impregnated petroleum gauze, Honey, Dakin’s solution or other agents. There are different dressings first are compresses (Fine mesh gauze, Hydrocolloid dressings, Silver containing dressings), then biosynthetic dressings(Biobrane, Polyhexanide), also there are biologic dressings (Allogenic skin grafts, Human amnion, skin xenografts), or barrier waterproof dressings. The last category is topical growth factors. (Tenenhaus et al., 2017)

Table 1.1

Antimicrobal activity with local treatment of burns

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Source: Larionova, 2014

1.6. Open and closed methods

Open method is recommended in all kind of burns but especially in face, neck and perineum. All those places where it’s difficult to change dressings. With the open method of treatment, the main task is the rapid formation of a dry scab, which is a biological dressing (prevents infection and contributes to epithelialization of the defect).

To do this, the drying effect of air, Ultra-violet lamp is used, it is possible to use some coagulating proteins of substances. Burning surface is treated with antiseptics with coagulating properties (5% solution of potassium permanganate, alcohol solution of brilliant green, etc.) and left open. It is important that around the wounds was dry warm air (26-28°C). The treatment is repeated 2-3 times a day. Thus, a dry scab forms on the wound surface.

In recent years, the open method is used in a controlled abacterial environment – in wards with a laminar flow of sterile warmed to 30-34°C air. Within 24-48 hours a dry scab forms, intoxication decreases, epithelization accelerates. Another modification of this method is treatment in boxed wards with infrared radiation sources installed in them and an air cleaner. Infrared rays penetrate deep tissues, moderately warming them, which accelerates the formation of a dry scab.

Significant progress especially in the treatment of the open method was facilitated by the introduction into clinical practice of special air-cushioned beds. The patient lying on such a bed, the tissues do not squeeze under the weight of the body, there is no additional violation of microcirculation and mechanical traumatization of the burned areas. (Noronha et al., 2000)

Closed method is based on the use of dressings with various medicinal substances. For burns of the 1st degree, an ointment bandage is applied to the damaged surface. Healing occurs within 4-5 days. Change of dressing, as a rule, is not carried out.

With burns of the II degree after the primary wound toilet, an ointment is applied, using ointments on a water-soluble basis, which have a bactericidal action (Levosulfamethacaine, etc.). Change of dressing is performed in 2-3 days. If purulent inflammation develops, an additional toilet of the wound is produced – bubbles are removed and moist-drying bandages are applied with solutions of antiseptics (Furacilin, Chlorhexidine, Boric acid).

With IIIa degree burns, a healthy skin toilet is made around the area of the injury and a dressing is applied. When treating such burns, it is necessary to strive for the preservation or formation of a dry scab – while the wound is faster epithelialized, less intoxication. If the affected area is a dry, light-brown, light-brown stripe, a dry bandage is applied. If the scab is soft, white-gray color, a wet-drying dressing with an antiseptic is used to dry the surface of the burn.

At the second or third week the scab is rejected. The burning surface is usually represented by either a gently pink epidermis or burned deep layers of the dermis. In the zone of non-epithelialized areas there may be a serous-purulent discharge. In doing so, use wet-drying dressings. To eliminate the purulent process for the acceleration of healing, ointment dressings are prescribed. Finally complete epithelization is completed in 3-4 weeks. Scars after healing are usually elastic, mobile. Only with the development of severe purulent inflammation can the formation of coarse scars.

With burns (III B and IV degree), local treatment is aimed at accelerating the rejection of necrotic tissues(see Table 2). Dressings are made every other day, which allows you to monitor the state of wounds. In most cases, given the severe pain syndrome with the removal of dressings and treatment of wounds, dressings are performed under anesthesia. It is advisable to use wound toilet with the application of moist dressings with antiseptics. In particular, mafenide (sulfamylon hydrochloride) is used, which can diffuse through dead tissue and affect the microbial flora in the dermal layer and subcutaneous tissue. (Alekseev, 2013)

In the chapter above main aspects of local burn care are defined, with excluding list of newly therapeutical agents. We also considered sensibility of pathogens to particular medicaments. In the next part we will take a look on early surgical treatments of burns.

Table 1.2

Close and open method compairison

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1.7. Local burn treatment with Dermazin cream

The basis of the ointment Dermazin is 1% Silver Sulphadiazine. Distributed along the surface of the wound, it provides a gradual release of silver ions. Silver microparticles are introduced into the DNA of harmful bacteria, stop their growth and reproduction. Treatment with dermazine is carried out open (uncoated with a bandage) and closed (coated with a dressing) until the wound is completely healed. It is important to consider that, treatment for more than 14 days with derivatives of silver provokes the development of superinfection.

From scientific sourses we found out, that sulfadiazine silver has a positive impact on the course of the wound process, giving anti-inflammatory and antiseptic actions (bactericid effect in relation to a wide range of bacteries, fungi or viruses). According to some authors, can stimulate exchange processes in cells, their proliferation and differentiation. (Tenenehaus, 2017)

1.8. Other issues on local burn treatment

Despite the simplicity of using the dressing method, more and more attention of clinicians is attracted by other approaches to the treatment of burns, consisting in early surgical tactics using modern biotechnologies based on cultured allof fibroblasts and synthetic coatings (Kolsanov et al., 2005; Zhirkova et al., 2006). The authors showed, that application of cellular technologies allows not only to reduce terms of restoration of the lost skin, but also to achieve good functional and cosmetic results of treatment. In this direction, collagen-containing wound coverings, which contribute to activation of reparative processes in the burn wound (Bodun et al., 2002), deserve attention. A large number of collagen sponge samples are known, which are used either as haemostatic drugs or to accelerate the healing of wounds. The haemostatic effect is mainly due to the high specific surface area of the sponge, which has many centers for the sorption of blood cells and plasma proteins (Jackson, 1996).

A number of authors used collagen as a component of the complex film coating forming the inner layer relative to the wound surface, on which the crushed xenogeneic demineralized bone matrix (DMC) was applied, in addition, antiseptics and an antibiotic were injected into the coating in order to suppress wound infection (Anfimov et al., 2005, Atiasova et al., 2010). Histological studies showed earlier appearance and maturation of granulation tissue in the experimental group of animals, in comparison with the control one, an increase in the production of collagen and a more pronounced development of epidermal regenerates with a basal layer. Along with this, the authors in the experiment revealed the proliferative effect of DMC on fibroblasts. Studies conducted by Anfimov, et al. (2004) showed the effectiveness of film coating, which consisted in reducing the epithelization time of dermal burns, the absence of traumatization of the wound bed and pain sensations in children with bandages.

Advances in cell biology have contributed to the creation of new science-intensive technologies, in particular, substitution cell therapy (Sarkisov, Benga et al.). The possibility of isolation and cultivation of the cells of the basal layer of the skin – keratinocytes allowed the researchers of the Institute cytology of the Russian Academy of Sciences to grow outside the body a multilayered layer, which is an analogue of the epidermis. When combined with cultured fibroblasts, a dermal skin equivalent (DEC) was obtained. In the Emergency care hospital of St. Petersburg, Russia conducted clinical studies that gave a positive result in the treatment of burn wounds on the developed technology (Blinova et al., 2004).

The treatment with the help of biological bandages based on pig skin is actively used, because, despite the wide choice of modern wound coverings, the problem of full closure of extensive wound defects in severely burned remains relevant (Malyutina et al., 2005). Komistiologists of Kazakhstan conducted research on the possibility of culturing human fibroblasts on xenograft from the peritoneum of cattle for further use in the treatment of extensive and deep burns in cases of a deficiency of donor material (Danlybaeva et al., 2013 ).

The use of wound coverings, which according to Antonov et al. (2010), are used in clinical practice, it allows to significantly improve the effectiveness of treatment of burn wounds, but most of them do not meet the requirements for them and can not be used in children with burns.According to Budkevich et al. (2006), when creating them, one must strive to combine a number of properties: the ability to create the optimal microenvironment, to possess a barrier function, elasticity, transparency, ease of use, and the absence of undesirable effects.

Clark (1993) and Kramer (2000) believe that the choice of wound coverings should be based on the early-acting functions of the applied dressings, as well as their ability to stimulate the healing process. Some authors put atraumaticity as one of the main requirements for modern bandages (Alekseev et al., 2005; Budkevich, 2005).

However, an understanding of what an ideal dressing should be, up to the present time has not been able to combine the above requirements in one universal facility.

Among the many forms of drugs used for the local treatment of burn wounds, a significant place is occupied by sponges made of synthetic or natural polymers (Nazarenko et al., 2002). The use of lipidicolloid wound coatings made it possible to reduce the frequency of bandage changes, provide comfort for patients and shorten the duration of treatment (Kopylov, 2013). Rimdeik (2013) and Brolmann (2013) recommend the use of occlusive hydrocolumbic or polyurethane dressings in areas that are particularly important from the cosmetic and functional point of view, which have an increased regenerative potential due to the abundance of deep epithelialization resources in the hair follicles and sweat glands.

1.9. Early surgical treatment of burns

In this part I want to study types of early surgical treatment of burns. It is important to know this type of the treatment because without it sometimes it´s not possible to treat burns. We are not going to consider full range of the burn surgical treatment, because it is not relevant for this study. First, we will study debridement.

Debridement is eschar removal its first step to prevent complications and initiating healing process. With this method burn-induced compartment syndrome can be prevented or reduced. Implementation of this method rely on deep of the wound. If burn surface is more than 50% TBSA of full thickness burns this method used very early and it is lifesaving. For less severe wounds debridement can be performed 2-4 days later after injury and may be postponed up to 2 weeks after injury, until diagnosis about burn depth may be established. After 3-4 days eschar removal can be only surgical. (Saunders, 2011)

1.10. Local burn treatment with silver nitrate

This is main theoretical chapter of our research, because our research will focuse on local burn treatment with silver nitrate solution. There are two diffent types of treatment in this cathegory: closed and coagulation methods. There are diffent concentration of solution used in thouse methods.

1.10.1. Nikolsky-Batman method

It is one of so called coagulating types of burn treatment. Here we will consider main aspects of local burn treatment with 5% solution of silver nitrate. This method has main focus in our study. We chose most used method, which is called Nikolsky-Batman. Let´s see this type of the treatment in details.

If treatment of the face by the Nikolsky-Batman method is performed within the next few hours after the burn, until the surface has been infected, the scars are much thinner than with the open method, that is, the cosmetic result is better.

In some cases, treatment with full success can be performed even on the 2nd or 3rd day after the burn; although in these terms the surface is partially infected, but after treatment with ethyl alcohol, tannin and Silver Nitrate (lapis), most of it heals under the crust. Sometimes after treatment of the face and head in the first days there comes a sharp swelling, which passes independently after 2-3 days.

After arriving patient receive, all anti-shock measures, he is given a warm soapy bath, which cleans the skin from contamination and simultaneously heats the patient. Then the patient is transferred to the operating room, where, under ether anesthesia, the wounds are treated as follows. A piece of gauze moistened with alcohol (in the absence of alcohol we use a warm 0.25% solution of ammonia or saline solution), the burned surface is cleaned of peeled epidermis and blisters. The latter, if necessary, are cut with scissors and removed with tweezers. Especially carefully, it is necessary to remove the epidermis at the edges of the blisters so that there are no detached pockets left. With a burn on the head, the hair should be shaved off. Then 5% solution of Taninum applied to burn surface, and then rub the surface of the burn with a 5% Silver Nitrate solution with another cotton wool. The surface quickly blackens, after a short time it becomes dry and crusted. A patient without a bandage is placed under a frame with bulbs, covered with a blanket, as is done with the open method. A thermometer is hung under the frame to monitor the temperature: the patient should be warmed at a temperature of 24-25 °, but not higher, in order to avoid overheating. With uninfected second-degree burns, the cortex lags behind as the epithelization of the wound and disappears on the 8th-11th day. With a partial removal of the crust of the edge, it is pruned with scissors. With third-degree burns, the cortex is separated later, and under it remains a granulating surface that is openly or under the bandage, depending on localization and other indications.

The method of Nikolsky-Batman has several advantages: the wound is protected from penetration of microorganisms; the crust prevents the loss of fluid from the large wound region, which eliminates not only dehydration, but also the loss of protein, which is released together with the wound exudate (plasmorrhea); loss of plasma reaches 2-3 liters per day. Thus, the absence of plasmorrhoea with coagulation treatment is a very important advantage. The scar turns out thin and gentle. In addition, this method provides peace for the wound and for the patient, since there is no soreness caused by the bandages during any movement or shifting in bed. The positive side of the method is also the cleanliness, absence of odor in the ward and saving dressing material.

The treatment is carried out in the next hours after the burn, until the surface has not had time to become infected. The location of the burn does not matter, it can be successfully burned on any part of the body, in particular on the hands, fingers and face. Scars after treatment on the face are obtained much thinner than with the open method, i.e. the cosmetic result is the best. In some cases, after treatment of the face and head in the first days there comes a sharp swelling, which passes independently after 2-3 days. A very important point is also absence of suppuration on the face after treatment, which protects the patient from infection. Thus, for the treatment of a face burn, the coagulating method is also the best.

(Atjasov et al., 2018)

1.10.2. Closed method with Silver Nitrate

For local treatment of burns, silver nitrate is also used, which has bacteriostatic properties and a wide range of antibacterial activity. After the toilet and drying on the wound, a thick layer of gauze is applied, which is impregnated with a 0.5% solution of silver nitrate. This bandage of about 3 cm thick is strengthened with a tubular mesh bandage and re-impregnated with the solution every 2 hours by wetting it or pouring it on a catheter „fixed in a bandage.” The dressing is changed 2 times a day, each time cleaning the wound.

One of the main advantages of the action of silver nitrate is the acceleration of the rejection of the burned scab. A burn wound, treated in this way, is ready for autologous plastic surgery 7-10 days earlier than with other methods of treatment. However, when treating with a 0.5% solution of Silver Nitrate, you should be very careful, as it has a number of characteristics – the dark color of the burn wound prevents monitoring of changes occurring in it, additional efforts of the operating personnel are required to change bulky dressings 2 times a day. In addition, silver nitrate poorly penetrates into tissues and affects mainly the surface microflora. If the patient enters the hospital a few hours after the lesion, immediately applied silver nitrate is very effective, but at a later date, when the infection in the burn wound begins to develop violently, the use of silver nitrate does not have a positive effect. In such cases, local treatment should be performed with another drug that penetrates quickly and deeply into the tissues.

A new local antibacterial drug called Sulfadiazine Silver was used by L. Fox in 1968. It was obtained as a result of the reaction of silver nitrate with a weak acid of sulfadiazine. A weak 1% solution of Silver Sulfadiazine (cream on a water-soluble basis) is applied to the wound 2 times a day in the same way as mafenide. The drug is effective in combating the numerous microflora of the burn wound, although it has only a bacteriostatic effect. Precipitation of chloride and silver sulphide does not occur to a very great extent, however, the wound acquires a silvery-gray color. By its ability to penetrate the wound and deep tissue, the drug takes place between Mafenide and Silver Nitrate. Although Sulfadiazine Silver is an effective agent for the prevention of burn sepsis, but with delayed treatment it is less effective than Sulfamilone (mafenide).

According to the Chief of Department of Plastic and reconstructive surgery Dr. Andreas Bajzat this type of treatment suits only for II a-b degree burns. Lower degree burns (ex. I-degree) can be treated localy with Dermazin cream or with open method. More severe cases as III and IV-degree burns usually need early surgical treatment already, because necrosis affected entire dermis and spontaneus healing not possible in this level any more.

The search for new drugs led to the production of antibacterial drugs, based on silver nitrate, as well as synthesized analogues of Sulfadiazine: zinc sulfadiazine and Cerium-sulfadiazine.

Here we saw briefly of local burn treatment by coagulation technique by Nikolsky-Batman method with silver nitrate 5% solution. It is based on fast closing area by organic crust, which aware body from losing water and prevent burn surface from pathogenic organisms invasion. Depend of the degree of burn crust is removed in therapeutic bath and new dermis appear under crust. Advantages of this method are thinner scars, absence of suppuration on the face and better healing. We will look into this method on our clinical research.

1.10.3. Silver nitrate pharmacodynamics

Silver Nitrate has antimicrobial, astringent (at a concentration of up to 2%), cauterizing (at a concentration of more than 5%) properties. During the dissociation of silver nitrate, silver ions cause the precipitation of proteins and cause bactericidal action. Silver nitrate interacts with tissue proteins, which leads to the formation of silver albumin. Then metal silver is recovered from the albumin, which interacts with the active groups of the enzymes, blocks them, thereby disrupting the metabolic processes in the microbial cell. In this regard, silver nitrate after a short-term bactericide has a long bacteriostatic effect. At small concentrations of silver ions, only the precipitation of interstitial proteins occurs and astringent and anti-inflammatory effects occur. In high concentrations, silver ions cause damage to cell membranes and intracellular structures, providing a cauterizing effect (friable albumins are formed). (Geotar, 2016)

1.10.4. Disadvantages of burn treatment with silver nitrate

Each drug has its side effects. But goal is to choose one that has less or minor side effects. So lets investigate side effects of Silver Nitrate.

Silver nitrate were not tested for carcinogenic effects on the animals. Silver nitrate is corrosive, in high concentrations it may severly irritate and burn the skin, also eyes, with future damage. If silver nitrate is inhaled it may irritate nose, throat or lungs. Exposure of Silver Nitrate to CNS may course headache, dizziness, nausea and vomiting. Bloods ability of oxygen transportation can be reduced by high dosis of silver nitrate, in this case headache, fatigue, dizziness occur. We face methemoglobinemia, blue color of skin and lips occur. Silver Nitrate may damage kidneys. If exposure to Silver Nitrate is repeated it can cause argyria(blue-gray discoloration of the eyes, skin and lips, also inner nouse, mouth, throat and internal body organs). It take years. But then its permament. It is not recomend to use in case of allergy, pregnancy or lactation perriod.

(New Jersey 2018)

Silver Nitrate is affecting human tissue only first 2-3h after application. After it create protective film. Then Silver Nitrate is inactive and has no chemical interract with human tissues. It is only natural protection of human tissues from outside pathogens to let epidermis renue itself and heal the wound. Therefore Nikolsky-Batman method has very minor side effects.

PRACTICAL PART

Practical part, second chapter of thesis consist of two subchapters:

1. First subchapter present motivation, research question retrospective statistic study, that took place in Arad County Clinical Hospital in Department of Plastic and Reconstructive Surgery, with patients who were admited with burn wounds in period 15.04.2017 – 15.05.2018. Then will be presented methods and tactics of this research.
2. In the second subchapter we will discribe study Nikolsky-Batman method in details. Then I will present clinical study steps and results in details. After this we will present of results of Silver Nitrate solution application on burn treatment using Nikolsky-Batman method. There will be statistical and morphological results, following the case presentation in Appendix.

CHAPTER II

2.1. Motivation

I choose topic about Nikolsky-Batman method of local burn treatment with silver nitrate, because I want to make my investigation about useful topic, the data I got can be implicated in daily practice and safe people lives or help in recovery process. Nowadays there is a lot of ways to treat burns, some of them are more comfortable to patient, some of them give better results in timing of healing, there are many factors, when surgeon choose type of treatment. In this work, I would like to concentrate on local burn treatment with silver nitrate. This method is investigated during World War II and it was used with great success direct after the war. It is still used in Romania, but unfortunately in higly developed contries like Finland in Helsinki burn centre in Jorvi Hospital it is not more in preferred as II a degree burn treatment (Jyrki Vuola 27.04.2018). Chief physician of above mentioned institution told me, that they favour nowadays modern wound dressings. In my opinion and opinion of chief physician of Department plastic and reconstructive surgery of Arad county Dr. Andrei Bajzat this method were forgotten with years with “help” of pharmaceutical companies, which introduce new wound dressings every year.

In this work we want to compare local burn treatment with silver nitrate and modern types of treatment. And find out the most effective, painless and cost-saving treatment in local burn treatment.

2.2. Research questions and methods

This chapter is dedicated to define the aim of this study, to find out how this research will be helpful for the author. And what goals would be achieved by this study. Also I will take a look at the methodology of this research, what are my tools to get information I need and to achieve the goals of this thesis. At the end of this chapter I will go more deeply in to the subject, define the participants of this research and criteria by which they are chosen. The research methods used in this study are case study of burn patients treated with silver nitrate.

2.2.1 Research Question

The aim of this study is to find and analyze theoretical material about local burn treatment, with focus on silver nitrate treatment. I need to study in general local burn treatment. Then in case study to compare silver nitrate treatment with other types of burn treatment to compare results. Finally it is possible to define the research question: To find out benefits and contraindications of local burn treatment with silver nitrate. Does this treatment suits to modern medicine standards and is it cost efficient? Is it pleasant and painful for the patient? Is it safe to patient, radiation danger? Does patient remain with scars or psychical problems.

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