Circumferential Burns, Escharotomy, and Extremity Compartment Syndrome

  1. Escharotomy is normally performed in the setting of a circumferential full thickness burn. If the burn is superficial or not circumferential and pulses are absent, first rule out hypovolemia, hypotension, or occult bleeding. Escharotomy incises the skin but not the fascia, and is usually sufficient for compartment syndrome caused by burns unless there is underlying muscle damage or over resuscitation. Refer to the Escharotomy Chart in Appendix E.
  2. The requirement for escharotomy or fasciotomy usually presents in the first 6-24 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. Elevation of the burned extremities 30-45° is required to decrease edema. 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 take into account the ability to transfuse the patient after the procedure.
  3. For any circumferential extremity (including fingers) burn, hourly monitoring is essential. The extremity should be elevated as high as feasible, especially during transport. Palpable radial pulses do not exclude digital compartment syndrome and digital pulses must be checked by using the Doppler to assess the palmar arch and digital arteries for hand and digit burns. In general, palpable pulses of the radial, dorsalis pedis and posterior tibialis is sufficient as long as there are no burns distal to these pulses. 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.
  4. Repeat the vascular exam at least every hour. If available, use handheld Doppler ultrasound to assess the palmar arch, dorsalis pedis, and posterior tibialis. A triphasic signal in the above vessels is considered normal. Consider performing escharotomy early, based upon the vascular exam. Consider fasciotomy in the operating room if pulses remain undetectable even after escharotomy. Continue hourly pulse checks to ensure adequate perfusion following surgical decompression.
  5. Escharotomy is performed by incising full thickness burns into the subcutaneous fat. Patients will require analgesia, sedation, and usually intubation. Because escharotomy can be associated with significant blood loss, at times it may be more prudent to rapidly evacuate the patient to a higher echelon of care rather than initiate the procedure in an austere environment. This is a judgment call based upon assessment of local resources and transportation time and availability.
  6. Using electrocautery to perform escharotomy reduces bleeding compared to a scalpel. Extend escharotomy incisions the entire length of the circumferential portion of full-thickness burn. The depth of the incision should be through the dermis to the level of subcutaneous fat; it is not necessary to carry the incision to the level of fascia. Carry incisions across involved joints. Although full thickness burn is insensate, patients will require IV narcotics and benzodiazepines during this procedure. On completion of the escharotomy, reassess perfusion. If circulation is restored, bleeding should be controlled with electrocautery and the extremity dressed and elevated at a 30-45° angle. Assess pulses hourly for at least 12-24 hours.
  7. Thoracic escharotomy incisions should extend from the neck, across the mid-clavicle, and down the anterior axillary line. Connect each side with an incision across the upper abdomen.
  8. In the upper extremities, place the hand in the anatomic position (palm facing forward) and make an incision in the mid radial or mid ulnar line, carrying the incision up the arm. Ulnar incisions should stay anterior (volar) of the elbow joint to avoid the ulnar nerve, which is superficial at the level of the elbow. If both hand and arm are burned, continue the incision across the mid ulnar or mid radial wrist and onto the hand. If circulation is not restored, perform a second incision on the opposite side of the extremity.
  9. If finger escharotomies are required, avoid functional surfaces (radial surface of the index finger and ulnar surface of the little finger). Place the fingers in a clenched position and note the finger creases at DIP and PIP joints. Escharotomy incisions should be just dorsal to a line drawn between the tops of these creases.
  10. Lower extremity escharotomy incisions are placed in the mid-lateral and/or mid-medial line extending from the ankle to the hip. If circulation is not restored, perform a second incision on the opposite side of the extremity.
  11. If bilateral extremity escharotomy incisions do not restore circulation, re-evaluate the adequacy of the patient’s overall hemodynamic status. Re-assess for a possible missed injury or ongoing bleeding.
  12. Consider fasciotomy in the operating room (OR) if pulses remain undetectable after escharotomy. Continue hourly exams to ensure adequate perfusion following interventions. Optimal fluid resuscitation and prompt escharotomy usually mitigates the need for fasciotomy. Due to the frequency of extremity injuries seen among combat casualties, fasciotomies on burned extremities may be required for those with delayed revascularization, hemorrhage requiring massive resuscitation, and crush injuries. For further details, see the JTS Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds CPG.4
  13. High altitude aeromedical evacuation is not, in and of itself, a contributor to the development of compartment syndrome in a burned extremity. Escharotomy/fasciotomy for thermal burns should only be performed for the clinical diagnosis of compartment syndrome, and if available, confirmed by measurement of compartment pressures.
  14. Following escharotomy or fasciotomy, late bleeding may occur as circulation is restored. Examine the surgical site every few minutes for up to 30 minutes for signs of new bleeding, which is usually easily controlled with electrocautery.