Escharotomy deserves renewed emphasis in the early care of the severely burned patient. In the acute management of deep circumferential burns of the extremities and upper trunk, escharotomy will often be the only effective means of restoring peripheral circulation and adequate ventilation. As reported in a recent issue of the Archives of Surgery , 1 Pruitt et al reviewed the experience at the US Army Surgical Research Unit with 55 burned patients requiring escharotomies during the first two days after they were burned. In deep circumferential burns of the extremity, the skin loses its elasticity and becomes rigid. Edema fluid accumulates under the eschar, with resultant impairment of venous and lymphatic return.
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NCBI Bookshelf. Lihan Zhang ; Patrick G. Authors Lihan Zhang 1 ; Patrick G. Hughes 2. Often, burns result in superficial first degree and partial thickness second degree burns, and less commonly full thickness third degree burns.
This is due to the inflexibility of the damaged tissue, which is the eschar that is formed. If untreated, this can result in distal ischemia, compartment syndrome, respiratory failure, tissue necrosis, or death.
Unlike fasciotomies, where incisions are made specifically to decompress tissue compartments, escharotomy incisions do not breach the deep fascial layer. The skin is made up of two layers, the epidermis and dermis, and their thickness varies depending on location, age, and gender. Deep in the skin is the subcutaneous fat and then a fascial membranous layer before the deeper structures, such as muscle.
Heat and other injury mechanisms can denature proteins, leading to loss of plasma membrane integrity and cell necrosis. Partial thickness burns involve both the epidermis and dermis; clinically, they can appear pink or cherry red, blister, are sensate to touch, blanch on pressure, and are also painful. Full thickness burns affect the epidermis, dermis, and subcutaneous tissue forming an eschar.
In limbs, circumferential full thickness burns act as a tourniquet, and restrict circulation distally, resulting in tissue ischemia and necrosis. On the chest and abdominal wall, due to the inflexible nature of the eschar, normal respiratory chest and abdominal wall movements are restricted thus limiting normal respiratory function.
Generally, escharotomy is performed when full circumferential thickness and sometimes partial thickness burns result in respiratory or circulatory compromise. For limb burns, it is performed if simple elevation does not improve circulation; for chest wall burns, this is performed if there is compromised respiratory function, which can occur even in non-circumferential burns; similarly, for abdominal wall burns, it is performed for compromised respiration due to the splinting effect on the diaphragm, especially in young infants under 12 months due to their predominant abdominal breathing pattern.
There are relatively few contraindications, due to the potential for limb- or life-threatening consequences if an escharotomy is not performed. It is not indicated in burns which will heal without surgical reconstruction superficial burns and when there is no compromise to respiration or circulation. This procedure does not require many instruments and can be performed at the bedside. A general anesthetic is not usually required, although sedation can be used.
A local anesthetic is required to infiltrate unburnt skin, into which the escharotomy will extend. A scalpel or cutting diathermy can be used to make the incision, and a diathermy cauterization device should be used to control bleeding. Ideally, an escharotomy should be performed by a plastic or burn surgeon or an experienced emergency medicine physician.
Before performing an escharotomy, appropriate advice and discussion should have taken place with the relevant burn specialist. The patient should be in a supine position, with the upper limbs supinated and the lower limbs in the neutral position. Incision lines should be marked on the patient and the area prepared and covered to maintain sterility. Structures at risk should be marked, such as the ulnar nerve at the medial epicondyle of the humerus and common peroneal nerve at the neck of the fibula, so that extra care can be taken to avoid damage to deep structures.
In the limbs, incisions should be made in the mid-axial line, both medially and laterally, and on the chest and abdominal wall, the incisions are made in the mid-axillary lines, which can be joined by a transverse incision below the costal margin to allow adequate release. The wound edges should be adequately parted upon incision; any residual constrictions should be checked by running a finger along the length of the incision. Cautery should be used to control post-procedure bleeding.
Once there is an adequate release of tissues, the incisions should be dressed with alginate dressings. Following escharotomy, the wounds should be monitored regularly, especially in the first 72 hours, due to high risk of bleeding, and for signs of incomplete releases, such as distal ischemia in limbs and poor ventilation for chest and abdominal burns.
Other complications include damage to deep structures, especially to ulnar and common peroneal nerves due to their relatively superficial course near the incisions. These wounds may require surgical reconstruction in the future, such as skin grafting, and may result in functional deficits as well as cosmetic problems. Full-thickness burns affect the normal function of the skin: temperature regulation, perspiration, skin elasticity, sensory function, and infection barrier.
For best results, an escharotomy should be performed with the help of an interprofessional team consisting of an experienced nurse and a plastic or burn surgeon or an experienced emergency medicine physician.
To access free multiple choice questions on this topic, click here. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U.
StatPearls [Internet]. Search term. Escharotomy Lihan Zhang ; Patrick G. Affiliations 1 Derriford Hospital. Anatomy and Physiology The skin is made up of two layers, the epidermis and dermis, and their thickness varies depending on location, age, and gender. Contraindications There are relatively few contraindications, due to the potential for limb- or life-threatening consequences if an escharotomy is not performed. Equipment Marking pen. Personnel Ideally, an escharotomy should be performed by a plastic or burn surgeon or an experienced emergency medicine physician.
Preparation The patient should be in a supine position, with the upper limbs supinated and the lower limbs in the neutral position. Complications Following escharotomy, the wounds should be monitored regularly, especially in the first 72 hours, due to high risk of bleeding, and for signs of incomplete releases, such as distal ischemia in limbs and poor ventilation for chest and abdominal burns.
Clinical Significance Full-thickness burns affect the normal function of the skin: temperature regulation, perspiration, skin elasticity, sensory function, and infection barrier.
Enhancing Healthcare Team Outcomes For best results, an escharotomy should be performed with the help of an interprofessional team consisting of an experienced nurse and a plastic or burn surgeon or an experienced emergency medicine physician. Questions To access free multiple choice questions on this topic, click here. References 1. Advances in surgical care: management of severe burn injury. Care Med. Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns.
J Burn Care Res. Out-of-hospital chest escharotomy: a case series and procedure review. Prehosp Emerg Care. Wong L, Spence RJ. Escharotomy and fasciotomy of the burned upper extremity. Hand Clin. Acute burns. Escharotomy in early burn care. Arch Surg. Escharotomies, fasciotomies and carpal tunnel release in burn patients--review of the literature and presentation of an algorithm for surgical decision making.
Handchir Mikrochir Plast Chir. Circulatory changes following circumferential extremity burns evaluated by the ultrasonic flowmeter: an analysis of 60 thermally injured limbs. J Trauma.
Pegg SP. Escharotomy in burns. Toussaint J, Singer AJ. The evaluation and management of thermal injuries: update. Clin Exp Emerg Med. In: StatPearls [Internet]. In this Page. Related information. Similar articles in PubMed.
Feasibility and safety of enzymatic debridement for the prevention of operative escharotomy in circumferential deep burns of the distal upper extremity. Epub Jan Escharotomy using an enzymatic debridement agent for treating experimental burn-induced compartment syndrome in an animal model. Review Escharotomy in burns. Ann Acad Med Singapore. Pressure guided surgery of compartment syndrome of the limbs in burn patients.
When the burn is a circumferential burned all the way around second and third degree burn, eschar will form and with the edema fluid leak from injured vessels formed; the pressure will increase in the burned area. If this happens in arms and legs, this will lead to compression of the underlying veins arteries and nerves acting like a tourniquet. If the circumferential burn happens in the neck or chest, the pressure will prevent chest expansion leading to breathing problems. In these situations escharatomy is often needed. Escharotomy is a surgical procedure done by making an incision through the eschar to relieve the underlying pressure, measuring the pressure in the compartment closed space of nerves, muscle tissue and blood vessels distal furthest to the affected area is one of the parameters used to determine the timing of escharatomy. Another way to determine the timing of the escharotomy is clinically by assessing the perfusion the flow of blood distal to the area affected.
Escharotomy and Burns
NCBI Bookshelf. Lihan Zhang ; Patrick G. Authors Lihan Zhang 1 ; Patrick G. Hughes 2.
ESCHAROTOMY IN BURN CARE
An escharotomy is a surgical procedure used to treat full-thickness third-degree circumferential burns. In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed eschar. Following a full-thickness burn, as the underlying tissues are rehydrated, they become constricted due to the eschar's loss of elasticity, leading to impaired circulation distal to the wound. An escharotomy can be performed as a prophylactic measure as well as to release pressure, facilitate circulation and combat burn-induced compartment syndrome. An escharotomy is performed by making an incision through the eschar to expose the fatty tissue below.