II. Indications

  1. Conditions
    1. Circumferential Extremity Full thickness burn (Third Degree Burn)
    2. Compartment Syndrome
  2. Findings
    1. Absent pulses and doppler pulses
    2. Compartment Pressure >40 mmHg (consider if >25 mmHg)
    3. Decreased limb Oxygen Saturation, while other limbs have normal Oxygen Saturation
    4. Abrupt limb neurologic symptoms

III. Pathophysiology

  1. Eschar is hard and inflexible and may result in a Tourniquet effect with tissue ischemia and necrosis
  2. Compartment Syndrome secondary to Burn Injury may also result in irreversible neurovascular injury

IV. Complications

  1. Neurovascular Injury
  2. Tissue Hemorrhage
  3. Wound Infection
    1. Careful wound management after Escharotomy is important
  4. Failed decompression with continued decreased tissue perfusion
    1. Fasciotomy may be required
    2. May require Limb Amputation
  5. Large scars
    1. Often require surgical reconstruction (e.g. skin grafting) later

V. Precautions

  1. Typically performed by burn center, Trauma surgery or general surgery
    1. However in resource limited areas, emergency providers may be tasked with Escharotomy
  2. Early intervention is associated with best outcome to prevent tissue ischemia, necrosis and amputation
  3. Escharotomy site selection is critical to prevent neurovascular injury to major structures
  4. Depth of incision (to subcutaneous fat) must be adequate to ensure tissue decompression
  5. Length of incision should extend from unburnt skin to unburnt skin (or superficial burn regions)
  6. Persistently high tissue pressures and decreased perfusion may require additional Escharotomy (e.g. opposite side of limb)
  7. Avoid Escharotomy of digits unless recommended by expert opinion

VI. Technique

  1. Consult with burn center or surgery as needed
  2. Plan Escharotomy incision to avoid major structures
  3. Clean and prepare incision site
    1. Antiseptic (e.g. Hibiclens)
    2. Local or Regional Anesthesia
  4. Incision
    1. Incision is longitudinal from proximal to distal extremity, on one side of the circumferential burn
    2. Start incision 1 cm outside of affected area
    3. Incise down to subcutaneous fat
    4. Continue incision to distal point of the affected area (1 cm into the uninvolved or superficially injured skin)
      1. If distal arm is affected, incision should extend to hypothenar or thenar eminence
      2. If distal leg is affected, incision should extend to fifth toe or great toe base
  5. Reassessment
    1. Incision on the opposite side of extremity is indicated for persistently decreased tissue perfusion in distal limb
    2. Ensure adequate depth of incision (down to subcutaneous fat)
  6. Wound care
    1. Wound bandaging

VIII. References

  1. Warrington (2020) Crit Dec Emerg Med 34(4):12-3

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