Quick and Dirty- ESCHARTOMY
Full-thickness skin burns result in the formation of a tough, inelastic mass of burnt tissue/eschar. By virtue of this inelasticity, there may be accumulation of fluid within the confined anatomic spaces underlying the eschar potentially resulting in a burn induced compartment syndrome. Briefly, compartment syndrome is defined as a compartmental pressure of >30mmHg leading to compromise of vascular, nerve, and lymphatic structures; and loss of tissue viability.
A circumferential eschar over the torso can lead to significant compromise of chest wall expansion, thus hindering ventilation. An extensive eschar involving the abdomen can lead to abdominal compartment syndrome. Similarly, airway patency and venous return may be compromised by circumferential burns involving the neck.
Escharotomy is an incision of the eschar, allowing decompression of the cutaneous tissues so that it becomes more compliant. Thus, the underlying tissues have an increased ability to expand, preventing further tissue injury.
- Impending or established vascular compromise of the extremities or digits
- Impending or established respiratory compromise due to circumferential torso burns
Vascular compromise can be established by frequent monitoring of capillary refill, doppler signals, and compartmental pressures.
As much as possible, escharotomy should be performed using sterile technique. Electrocautery is ideal in anticipation of substantial blood loss.
In the severely burned patient who is obtunded and intubated, no anesthesia is required because the eschar is nonviable tissue with complete destruction of nerve endings.You may want to be thoughtful of your conscious patient and consider procedural sedation.
Recheck compartmental pressures after escharotomy. In some cases, concomitant fasciotomy may be necessary
There is no evidence to support prophylactic antibiotics. However because exposed tissue is a potential source of infection, wounds should be treated with topical antimicrobial dressings.
- Use electrocautery to create incisions in the eschar up to the level of the subcutaneous fat.
- Carry the incisions approximately 1 cm proximal and distal to the extent of the burn.
- Areas overlying joints have densely adherent skin, and the incisions should extend across joints to allow for decompression of neurovascular structures. Take care to avoid damage to the neurovascular bundles that run superficially and near joints.
- Escharotomy incisions for the limbs should be carried to the level of the thenar and hypothenar eminences for the upper extremity and to the level of the great toe medially and the little toe laterally for the lower extremity.
- Limb escharotomy incisions run in close proximity to superficial veins, and these veins should be identified and preserved.
- Digital escharotomy should be performed by a practitioner with experience in hand surgery for burns whenever possible. The locations of the incisions for decompression are near the digital neurovascular bundles, and injury to these can lead to profound and permanent loss of function.