Emergency Medicine Book

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Limb Escharotomy

Aka: Limb Escharotomy, Escharotomy, Burn Escharotomy
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. Resources
    1. Escharotomy (Stat Pearls)
      1. https://www.ncbi.nlm.nih.gov/books/NBK482120/
    2. Escharotomy (Wiki EM)
      1. https://wikem.org/wiki/Escharotomy
    3. Escharotomy with Video (VicBurns)
      1. https://www.vicburns.org.au/severe-burns/early-management/escharotomy/
    4. Escharotomy with Video (UW)
      1. https://www.uwmedicine.org/provider-resource/videos/burns-102-escharotomy-for-3rd-degree-full-thickness-burns
  7. References
    1. Warrington (2020) Crit Dec Emerg Med 34(4):12-3

Escharotomy (C0191309)

Concepts Therapeutic or Preventive Procedure (T061)
ICD10 30017-00
SnomedCT 70177008
CPT 16035, 16036, 1003562
Italian Escarotomia
Japanese 焼痂切開, ショウカセッカイ
Czech Protětí příškvaru
English ESCHAROTOMY FIRST INCISION, INCISION OF BURN SCAB INITI, escharotomies, escharotomy, Incision of burn scab initi, Escharotomy; initial incision, Escharotomy, initial incision, Escharotomy, Escharotomy (procedure)
Hungarian Hegkimetszés
Spanish Escarotomia; incision inicial, escarotomía (procedimiento), escarotomía, Escarotomía
French Escarrotomie
Portuguese Escarotomia
Dutch escharotomie
German Schorfoeffnung
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Escharotomy of burnt skin (C0411707)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 240992000
English Escharotomy of burnt skin, Escharotomy of burnt skin (procedure)
Spanish escarectomía de piel quemada (procedimiento), escarectomía de piel quemada
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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