Escharotomy

Indications

  • Circumferential eschar with any of:
    • Restricted ventilation (torso)
    • Vascular compromise
    • Compartment syndrome (compartment pressure > 30 mmHg)

Contraindications

  • No absolute contraindications

Considerations

  • Irreversible ischemia of a gangrenous limb may render escharotomy futile
  • Elevated INR
    • Give Vitamin K +/- FFP but do not delay procedure
  • Thrombocytopenia
    • Transfuse platelets, but do not delay procedure
  • Skin infection
    • Not a contraindication

Equipment Needed

  • Sterile prep equipment
  • Scalpel or electrocautery
    • Electrocautery preferred when available
  • Burn dressings
  • Topical antibiotics

Procedure

  • Document neuro-vascular status
    • Consider Doppler ultrasound and compartment pressure if there is suspected need for an extension of the escharotomy or simultaneous fasciotomy
  • Incise eschar with scalpel or electrocautery, extending at least 1 cm into normal, unburned skin
  • Depth of incision controversial
    • Most recommend incision into subcutaneous fat
  • Apply burn dressing
    • Silver sulfadiazine or antibiotic ointment with petroleum gauze
  • Note that local anaesthetic is usually unnecessary as full thickness burns are insensate

Specific Techniques

Torso

Shield incision.JPG
  • Incise at anterior axillary line from level of 2nd rib to 12th rib bilaterally
  • Join incisions transversly with one incision slightly inferior to the clavicle and a second along the upper abdomen

Extremities

Feet.JPG
Lower extremities.JPG
Upper extremity.JPG
  • Extensive escarotomies of the limbs should be carried to thenar and hypothenar eminences for upper extremities, and great and little toes for lower extremities
  • Identify superficial veins and avoid if possible
  • If possible, digital escharotomy should be performed by a hand surgeon
    • If plastic surgery expertise is not immediately available, incise along the mid-lateral portion of fingers and toes
  • Avoid the posterior to medial malleoli of the ankle due to superficial neurovascular structures
  • Avoid flexor surfaces of elbows, wrists, and knees
    • Escharotomy must still be performed over joints, as these are susceptible areas of high tension

Complications

  • Actually have minimal bleeding due to full thickness burns

See Also

External Links

https://www.youtube.com/watch?v=puU4aDuhc0g

References

  • Peck, Michael. Arizona Burn Center. Escharotomy Procedures for Burn Patients. May 26, 2015.