THE USE OF SALICYLATE VASELINE IN THE DEBRIDEMENT OF BURNS

Maviglio R, Mavilio D., De Donno G., Rume D.

Ospedale Regionale, Divisione di Chirurgia Plastica e Centro Ustioni, Brindisi, Italia

SUMMARY. Although surgical escharectomy is the generally accepted method of choice for the elimination of bum eschars, particular conditions may exist when this technique is not possible. It is therefore necessary, in order to avoid the risk of septic complications, to remove the eschar by other means. Salicylate vaseline was used for this purpose in over 500 patients over a period of 15 years with good results. This ointment has no limitations, and it also has the advantage of being easy to apply, apart from being inexpensive and easy to prepare.

In this short paper - the fruit of long experience - we wish to offer our contribution to the solution of one of the most complex problems encountered in the treatment of the severely burned patient: the debridement of necrotic areas.
With adequate hydroelectrolytic resuscitatory treatment it is rare to observe deaths in the days immediately following the bum trauma, whereas towards days 15/20 severe septic complications may set in, favoured by the presence of considerable immune depression and a liquefying eschar which constitutes excellent growth pabulum for germs.
These complications are the most frequent cause of patient deaths. It is evidently of great importance to eliminate the necrotic tissues and to re-cover the patient as soon as possible.
We too are convinced that early surgical necrectomy must be the method of choice. However it is very often impossible to bring the patient to the operating theatre, for a number of reasons - the gravity and the extent of the burns, the serious anaesthesiological risk in connection with the operation, the presence of airway lesions and last but not least the difficulty of distinguishing at such an early stage truly necrotic zones from others that are still viable.
These considerations make it necessary to have at our disposal valid alternative methods, and many researchers are still today looking for a chemical compound capable of accelerating the elimination of skin necroses.
Ideally, the characteristics of such an agent are that it should prevent later blood loss during its debriding action

• be non-toxic for the patient
• be able to remove necrotic tissue without damaging viable tissue not increase the rate of infective complications not,compromise subsequent graft take.

In past years Travase was widely used. This is a substance of enzymatic nature extracted from Bacillus Subtilis which allows rapid elimination of the eschar (in about 8 days); Travase has however been much criticized because its use leads to an increase in infective complications (although this was denied by V. Pennisi, the first proposer of the method) and because it is possible to treat at one and the same time only limited burned body surface areas (no more than 15%).
We have long been interested in salicylic acid, an agent that is already well known to dermatologists for its notable keratolytic properties; by acting on the junction between necrosis and healthy tissue it causes the lysis or loosening of the elastic fibres, of the bridges of residuous collagenous tissue, and of the coagula and thrombi of fibrin, thus accelerating its elimination. In addition to this activity salicylic acid also has bacteriostatic and germicide properties.
Salicylic acid, applied in the medium of white vaseline, can be better distributed over the surface to be treated and absorption by the tissues can be controlled by modification of its concentrarion.
This absorption in our experience does not lead to pathological accumulations: we have never seen a case of serious intoxication due to salicylic acid. This may occur as a result of an excessive accumulation of high doses. The toxic symptoms (see Table), although they may be related to the concentration of salicylic acid in the serum, present a certain individual variability. Clinical and pharmacological studies have however demonstrated that toxic symptoms do not appear in the presence ot- scrum concentrations lower than 15 mg/%, appear rarely in concentrations lower than 30 mg/%, and usually occur in concentrations over 50 mg/%.

We use salicylate vaseline from day 3/4 post-burn in concentrations varying from 5 to 20%. The concentration depends on the site, the depth and the type of burn.
In intermediate second-degree burns of the face we use 5% concentrations, spreading the ointment directly on the lesions, using the method described; the wound is delicately dressed every day with physiological solution. Debridement occurs gradually and is complete by day 10, with the spontaneous presence of ample reepithelialization zones and the absence of excessive secretions and infections.
In intermediate-deep second-degree burns and in third-degree burns caused by hot water we generally use 10- 15% concentrations, especially when the burn area exceeds 20%.
In third-degree flame burns we use 20% vaseline, after performing some escharectomic incisions. We apply the salicylate vaseline, spreading it on greased gauze and using occlusive bandages. The dressing is changed every other day, if necessary with the assistance of balneotherapy. After about 4 dressings the progressive loosening of the necrosis becomes evident and is complete on about day 14. On about days 10/12 the eschar begins to detach itself (Fig. 1) and, similar to wet cardboard (Fig. 4), it is easily removed with forceps and blunt scissors (Fig. 2); the underlying tissue bleeds very little (Fig. 3), and the pain is tolerable so that the patient has to be sedated only in the case of extensive lesions.
The debrided areas are covered with pig skin (E-Z derm) and when the cleansing procedures are complete they are placed under packs of physiological solution mixed with the antibiotic that has proved to be sensitive to the antibiogram which we regularly perform every 3 or 4 days after the patient's hospitalization.

Fig. 1 Third-degree bums in 25% body area: day 11, initial detachment of eschar. Fig. 2 Same case, day 13: eschar removed with scissors and forceps. Fig. 3 Same case: . appearance of granulating surface after escharectomy.

It is generally possible to operate on the patient between day 20 and day 22 (Fig. 5). The take of the graft and the subsequent scar are both good, and are not unlike the results obtained with surgical escharectomy.
During treatment we naturally monitor the degree and nature of any infections, which are controlled by aimed antibiotic therapy by general means. The patient is placed on a Clinitron airbed, if available, and all therapeutic measures are performed that are necessary for the optimal course of the disease. The monitoring must be watchful for salicylaemia and the appearance of any clinical signs of intoxication.

Fig. 4 Same case: "wet cardboard" appearance of removed eschar. Fig. 5 Same case, day 22: patient ready for operation.

We have used the method described with good results for over 15 years in over 500 patients with severe bums with over 20% BSA in adults and over 10% in children. On the basis of this wide experience we can make the following affirmations: the method is easily handled and has no limitations of any kind; debridement occurs in about 14-16 days with the formation of a good granulation tissue which is ready to receive the graft on day 20-22; the patients are discharged after 35-40 days of hospital treatment.
Salicylate vaseline does not seem to affect bacterial growth or provoke an increase in infections, and salicylaemia was always maintained under values of 30 mg/%; the rare cases of initial intoxication were satisfactorily treated by simply suspending the application of salicylate vaseline.
Last but not least, one consideration should not be neglected: the low cost of the ointment, which is prepared directly in the hospital pharmacy.

Symptoms of salicylism

• initial:
  • vertigo, tinnitus
• subsequent:
  • nausea, vomiting, diarrhoea, disturbances of the sight, momentary mental aberration
• advanced:
  • mental confusion, excitement, talkativeness, restlessness, respiratory alkalosis

RÉSUME. Bien que l'excision chirurgicale soit la méthode généralement préférée pour l'élimination des escarres des brûlures, cette technique n'est pas toujours praticable, à cause de conditions particulières. En ce cas, pour éviter le risque des complications septiques, il faut détacher l'escarre en manière diverse. Pour atteindre ce but, les Auteurs ont utilisé la vaseline salicylée chez plus de 500 patients dans une période de plus de 15 ans, avec de bons résultats. Cet onguent n'a pas de limitations, il a l'avantage d'être facile à appliquer, il coûte peu et sa préparation est aisée.

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