You’re on a lovely amble through the backcountry when suddenly you see smoke rising nearby and catch a whiff of a familiar scent that throws you back to your med school OR days: burning flesh. You quickly find one obtunded, severely burned hiker who inadvertently set fire to his camp.
After a quick airway assessment – no soot or burns in the oropharynx, thankfully, since you can’t intubate anyway – you astutely proceed to quantify the burns. The following image immediately comes to mind:
As you proceed calculate the total body surface area burned (the entire front of the torso, back of the torso…that’s 36%) in order to apply the Parkland formula which you’d always committed to memory…
4 x weight (kg) x %burned = total IVF in mL over 24 hrs (half over the first 8 hrs, half over the next 16) – our patient would be 4x70x36=10080mL or approx 10L total over 24 hrs
…you note the patient’s respirations begin to become more shallow. Uh oh…this guy has a full-thickness circumferential chest wall burn! What are you gonna do?
Chest escharatomy
A consequence of full-thickness burns is the formation of an eschar, burnt tissue which is inelastic and constricting; in circumferential burns, along with tissue edema from the burn, this can lead to compartment syndrome – of the extremities, abdomen, and chest. In severe torso or neck burns, this constriction can cause respiratory or airway compromise requiring escharotomy.
Fortunately, you always travel with a scalpel (though sadly you left the electrocautery at home) cause you’re that kinda guy. You make two lengthy incisions – just through the eschar; this is distinct from a fasciotomy – along the anterior or mid-axillary line bilaterally, and a transverse incision below the costal margin across the abdomen as seen below. The patient’s ventilation improves and you move onto figuring out an evacuation plan.
References:
Rice, P. Emergency care of moderate and severe thermal burns in adults. UpToDate. Accessed on June 3, 2019.
Zhang L, Hughes PG. Escharotomy. [Updated 2019 Apr 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK482120/
Calculator: Adult burn injury fluid resuscitation (Parkland crystalloid estimate). UpToDate, accessed at https://www.uptodate.com/contents/calculator-adult-burn-injury-fluid-resuscitation-parkland-crystalloid-estimate
