In the spirit of roasts and fire-breathing dragons


    In the spirit of roasts and fire-breathing dragons

    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.



    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:

    Calculator: Adult burn injury fluid resuscitation (Parkland crystalloid estimate). UpToDate, accessed at



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