- Dashed lines indicate the preferred sites for escharotomy incisions.
- Bold lines indicate the importance of extending the incision over involved major joints.
- Incisions are made through the burned skin into the underlying subcutaneous fat using a scalpel or electrocautery.
- For a thoracic escharotomy, begin incision in the midclavicular lines.
- Continue the incision along the anterior axillary lines down to the level of the costal margin.
- Extend the incision across the epigastrium as needed.
- For an extremity escharotomy, make the incision through the eschar along the midmedial or midlateral join line.

Source: Figure 26.2-1 Emergency War Surgery; Fourth United States Revision; 2013 (page 379).

CLINICAL INDICATIONS:

Deep partial-thickness or full-thickness circumferential burns to arms or legs.

- This may mimic compartment syndrome or act like a tourniquet, reducing arterial circulation resulting in ischemia or necrosis of the limb.
- Pulses will feel diminished on exam even after elevation.

Circumferential, full thickness burns to the chest wall.

- This can result in restriction of chest wall expansion and decreased compliance causing difficulty oxygenating and ventilating of intubated patients.
- Clinical manifestations of chest wall restriction include rapid, shallow respirations; poor chest wall excursion; and severe agitation.

CONTRAINIDICATIONS: No contraindications

EQUIPMENT:

1. Scalpel, an electrocautery device, or both
2. Chlorhexidine prep
3. Combat gauze and Kerlix
4. Sterile towels

PROCEDURE:

1. Remove patient’s rings, watch, and other jewelry during the initial examination.

2. Prep sterile items/equipment.

3. Outline or identify landmarks.

4. Follow guidelines to make escharotomies bilaterally (medial and lateral) down to the subcutaneous tissue.

a. Preferred sites of escharotomy (dashed and solid lines). Particular care is needed to divide eschar over involved joint (solid lines). Care must be taken to avoid major nerves, vessels, and tendons.

b. The incision along the extremities should extend through the length of the eschar, over joints, and down to the subcutaneous fat, laterally and medially.

c. Chest incisions usually are made bilaterally along the anterior axillary lines and are connected by a transverse incision at the costal margin.

5. Repeat pulse exam in all extremities, if there is no return of circulation return to step 4.

6. Achieve hemostasis with combat gauze and dry Kerlix.

7. Skin color, sensation, capillary refill, and peripheral pulses are assessed and documented hourly.