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

• 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

• 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

• Burns

External Links

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