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 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
- Local anesthesia in areas of full thickness burns may not be necessary
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 sensation
- 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
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.