CIRCUMFERENTIAL BURNS, ESCHAROTOMY, & EXTREMITY COMPARTMENT SYNDROME

Escharotomy is normally performed for circumferential full thickness burns.

Check pulses (preferably using a Doppler flowmeter if available). If pulse is decreased or absent:

- Rule out hypovolemia.
- If not hypovolemic, perform escharotomies.

Escharotomy incises the skin only, not the fascia and is usually sufficient for limb ischemia caused by burns unless there is underlying muscle damage, over-resuscitation, or combined injury. The requirement for escharotomy or fasciotomy usually presents in the first 48 hours following injury. If the need for either procedure has not been identified within the first 24-48 hours, then circulation is likely to remain adequate without surgical intervention.

- A patient who required escharotomy or fasciotomy at a lower echelon of care should always have their extremity compartments reassessed upon arrival at the next echelon of care. Extension of the incision(s) may be required to restore circulation. This situation can occur if large IV fluid volumes are given during transport, compounding tissue edema. The threshold for escharotomy should be low in patients requiring transportation but must consider the ability to monitor.
- Absent Doppler signals or pulses that are diminishing on hourly exams should prompt immediate consultation with a burn surgeon and strong consideration of surgical decompression with escharotomies.
- Repeat the vascular exam hourly. If available, use a handheld Doppler flowmeter to assess the palmar arch and the radial, ulnar, dorsalis pedis, and posterior tibialis arteries. A triphasic signal in the above vessels is considered normal. Consider performing escharotomy early, based upon the vascular exam.

Elevation of the burned extremities (especially the upper extremities) above the level of the heart is required to decrease edema and prevent compartment syndrome.

Escharotomy

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

- Escharotomy is performed by incising circumferential full-thickness burns.
- Extend escharotomy incisions the entire length of the circumferential portion of full-thickness burn.
- The depth of the incision should be through the dermis into the subcutaneous fat. Carry incisions across involved joints (Figure 2).
- Although full thickness burn is insensate, this is a painful procedure, and patients will often require moderate sedation with benzodiazepines and IV narcotics.
- An escharotomy performed to the proper depth should not result in significant bleeding, especially if electrocautery is used. The bleeding that does occur can usually be controlled with electrocautery or topical hemostatics (i.e., Combat Gauze, Avitene). It may require suturing using a silk stitch.
- Upon completion of the escharotomy, reassess perfusion. If circulation is restored, the extremity should be dressed and elevated above the level of the heart. Continue to assess pulses hourly for at least 12-24 hours.