Escharotomy

Indications

Escharotomy Burn Indications

  • Circumferential eschar with one of the following:
    • Circumferential torso - restricted ventilation
    • Circumferential extremities - vascular compromise
  • Immediate escharotomy if compartment pressure > 30 mmHg
  • Elevate limb and optimize fluid status

Contraindications

  • No absolute contraindications; irreversible gangrenous limb may be futile
  • Elevated IRN: not a contraindication. Give vitamin K, FFP as needed
  • Skin infection: not a contraindication
  • Thrombocytopenia: not a contraindication. Give platelets.

Equipment Needed

  • Sterile prep equipment
  • Scalpel in austere or ED environment without electrocautery
  • Burn dressings and topical antibiotics

Procedure

  • Baseline neurovascular exam with serial neurovasc checks with Dopplers and compartment pressures to assess for need to extend escharotomy and/or add fasciotomy
  • Depth of incision controversial, may require as little as dermal release to complete subcutaneous release to fasciotomy
  • Apply silver sulfadiazine dressings or antibiotics with petroleum gauze after escharotomy

Torso

Shield incision.JPG
  • Incise at ant axillary line from level of 2nd rib to 12th rib bilaterally, incising down to level of subcutaneous fat
  • May have an immediate release manifested by popping sensatio
  • Join these two incisions transversely

Extremities

Feet.JPG
Lower extremities.JPG
Upper extremity.JPG
  • Extensive escarotomies of the limbs should be carried to thenar/hypothenar eminences for UEs, and great/little toe for LEs
  • Limb escharotomies are close to superficial veins, so identify if possible
  • Digital escharotomies should be performed by hand surgeon if at all possible
    • Restricted perfusion (focal)
    • Perform along midlateral portion of fingers/toes, extremities if no pulse by Doppler
  • Ankles - avoid posterior to medial malleolus due to neurovasculature
  • Hands and feet - incise along dorsal interossei muscles; pay close attention to DP in feet
  • Joints
    • Avoid flexor surfaces of elbows, wrists and knees as shown in attached pictures
    • However, it is important to release over joints due to high tension at these sites

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.