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
• Apply silver sulfadiazine dressings or antibiotics with petroleum gauze after escharotomy

Torso

• 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

• 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

See Also

• Burns