Escharotomy


Article Author:
Lihan Zhang


Article Editor:
Patrick Hughes


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Dustin Constant
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Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/28/2019 11:29:50 AM

Introduction

Burns commonly present acutely to clinicians due to various modalities, such as thermal, chemical, electrical or radiation. Often, burns result in superficial (first degree) and partial thickness (second degree) burns, and less commonly full thickness (third degree) burns. Burn depth usually is determined by the intensity of the source, duration of contact, and location on the body.[1]

Circumferential, full-thickness burns, whether on limbs or trunk can produce a splinting or tourniquet effect which compromises circulation and reduces muscle movement. 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.[1],[2] Escharotomy is an emergency surgical procedure involving incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal circulation, and allow adequate ventilation [3]. Unlike fasciotomies, where incisions are made specifically to decompress tissue compartments, escharotomy incisions do not breach the deep fascial layer.[4] 

Anatomy

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. Superficial burns only affect the epidermis; they are clinically painful, erythematous, blanch on pressure, and are sensate. 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. Clinically, these burns appear dry and leathery, but they are not painful, sensate, or blanching and can feel firm and waxy on palpation. [5]

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.[1],[6] 

Indications

Escharotomies often are performed as part of a burn victim's resuscitation care, and the decision is made based on clinical assessments of the patient and their response to treatment provided prior to that assessment. Clinically, patients may complain of tingling or numbness in limbs; the affected areas may be cool to touch, have reduced oxygen saturation, a delayed or no capillary refill, and reduced distal Doppler signal.[7],[8] On the chest and abdomen, signs may include shallow respiratory effort, and restricted chest and abdominal wall movement. [9] The escharotomy is usually performed within the first 48 hours of injury, due to initial injury from the primary source, and secondarily due to resuscitation and development of tissue edema.[2]

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. 

Contraindications

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. 

Equipment

  • Marking pen
  • Local anesthetic +/- sedation
  • Sterile preparation, such as chlorhexidine or non-alcoholic povidone-iodine
  • Sterile drapes
  • Scalpel +/- cutting diathermy
  • Diathermy cauterization device
  • Alginate dressing

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.[5],[1],[4],[10] 

Personnel

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. 

Preparation

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. 

Technique

The incisions should extend from unburnt skin to unburnt skin ideally, or at least into areas of more superficial burns, down to subcutaneous fat, and release any constrictions. 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. [11]

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. 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. 

Clinical Significance

Full-thickness burns affect the normal function of the skin: temperature regulation, perspiration, skin elasticity, sensory function, and infection barrier. Circumferential full-thickness burns with resultant loss of skin elasticity can produce a tourniquet effect on limbs and trunk, which can lead to compromised distal perfusion, airway obstruction, and poor respiratory effort. All of which could lead to limb- or life-threatening situations, which may be avoided through early and adequate burn resuscitation, including escharotomy, to release circumferential full-thickness burns.

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. [Level V]


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Escharotomy - Questions

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When performing limb escharotomy, the incision should run parallel to which of the following?



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A 34-year-old male with no previous medical history presents to the emergency department after exposure to an errant firework. Examination reveals a cherry red blister that is painful to touch circumferentially on his right upper extremity. The patient has a 2+ radial pulse, and capillary refill is less than 2 seconds in his affected extremity. The patient denies any change in sensation or weakness. What is the next best step in the management of the injury?



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A 65-year-old male presents to the emergency department after a burn to his left upper extremity. Examination reveals a leathery circumferential eschar without pain to his affected extremity. His left arm is cool to the touch and no pulse is palpated, and an immediate escharotomy is performed. On re-examination, the patient is noted to have a decreased sensation and weakness in his left fourth and fifth digit. What is the most likely cause of the patient’s neurologic deficits?



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A 48-year-old female present to the emergency department after falling into a fire pit. Examination reveals a eschar circumferentially around her right lower extremity and a reduced distal doppler signal. What is the next best step in management of the injury?



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A patient is seen in the emergency department after suffering a third-degree burn to his right leg several days ago. He was treated at another facility, but the family were unhappy and decided to take him to another facility. Ar presentation, quick examination reveals a thick band of burnt tissue around the right mid-calf area and a cold lower extremity, which is blue. The proximal leg appears edematous and swollen. What is the most appropriate next step in management?



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A 24-year-old male with no previous medical history presents after a burn injury from a house fire. Examination reveals a circumferential, full-thickness burn to the right lower leg with decreased pulses distal to the burn. An immediate escharotomy is performed. On re-examination, the patient is noted to have decreased sensation to the lateral leg and weakness with dorsiflexion of the foot. Which of the following is the most likely cause of the patient’s neurologic deficits?



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Escharotomy - References

References

Kupas DF,Miller DD, Out-of-hospital chest escharotomy: a case series and procedure review. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2010 Jul-Sep;     [PubMed]
Grunwald TB,Garner WL, Acute burns. Plastic and reconstructive surgery. 2008 May;     [PubMed]
Pegg SP, Escharotomy in burns. Annals of the Academy of Medicine, Singapore. 1992 Sep;     [PubMed]
ISBI Practice Guidelines for Burn Care. Burns : journal of the International Society for Burn Injuries. 2016 Aug;     [PubMed]
White CE,Renz EM, Advances in surgical care: management of severe burn injury. Critical care medicine. 2008 Jul;     [PubMed]
Orgill DP,Piccolo N, Escharotomy and decompressive therapies in burns. Journal of burn care     [PubMed]
Wong L,Spence RJ, Escharotomy and fasciotomy of the burned upper extremity. Hand clinics. 2000 May;     [PubMed]
Pruitt BA Jr,Dowling JA,Moncrief JA, Escharotomy in early burn care. Archives of surgery (Chicago, Ill. : 1960). 1968 Apr;     [PubMed]
Piccolo NS,Piccolo MS,Piccolo PD,Piccolo-Daher R,Piccolo ND,Piccolo MT, Escharotomies, fasciotomies and carpal tunnel release in burn patients--review of the literature and presentation of an algorithm for surgical decision making. Handchirurgie, Mikrochirurgie, plastische Chirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse : Organ der V.... 2007 Jun;     [PubMed]
Moylan JA Jr,Inge WW Jr,Pruitt BA Jr, Circulatory changes following circumferential extremity burns evaluated by the ultrasonic flowmeter: an analysis of 60 thermally injured limbs. The Journal of trauma. 1971 Sep;     [PubMed]
Toussaint J,Singer AJ, The evaluation and management of thermal injuries: 2014 update. Clinical and experimental emergency medicine. 2014 Sep;     [PubMed]

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