What clinical manifestation indicates that an Escharotomy is needed on a circumferential extremity burn *?

Eschar is stiff, dead skin tissue caused by deep 2nd- or 3rd-degree burns. Circumferential eschar on a limb constricts distal circulation, and eschar on the thorax constricts respiration. Escharotomy is surgical incision through the eschar to release the constriction, thereby restoring distal circulation and allowing for adequate ventilation.

Escharotomy is usually done within the first 2 to 6 hours of a burn injury. Unlike fasciotomies, where incisions are made specifically to decompress tissue compartments, escharotomy incisions do not breach the deep fascial layer.

• Eschar compressing or potentially compressing tissue in or surrounding burn area

Compressed tissue is identified by any of the following:

• Absent distal arterial flow as determined with a Doppler ultrasonic flow meter in the absence of systemic hypotension

• An oxygen saturation below 95% in the distal end of the extremity as shown by pulse oximetry in the absence of systemic hypoxia

• Measurement of compartment pressure > 30 mm Hg

• Impending or established respiratory compromise due to circumferential torso or neck burns

Physicians should have a high index of suspicion and a low threshold for doing escharotomy.

• None

Complications from the procedure include

• Bleeding

• Infection

• Damage to underlying neurovascular structures

• Inadvertent fasciotomy

• Sterile drapes

• Cleansing solution, such as povidone-iodine or chlorhexidine

• 25- and 21-gauge needles

• 10-mL syringes

• Local anesthetic, such as 1% lidocaine

• #11 scalpel and/or electrocautery device

• Sterile gauze

• Topical antimicrobial such as bacitracin or mupirocin*

• Sterile gloves

• Eschars occur in full-thickness burns or, less commonly, deep partial-thickness burns through at least the dermis.

• A properly executed escharotomy releases the eschar to the depth of subcutaneous fat only. This release results in minimal bleeding, which can be controlled with local pressure or electrocautery.

Major neurovascular structures to avoid when incising at the following sites include

• Elbow: Ulnar nerve

• Wrist: Radial nerve

• Fibular head: Superficial peroneal nerve

• Ankle: Posterior tibial artery

• Neck: Jugular veins

• Penis: Dorsal vein

• Patient comfort with excellent exposure of burned areas

• Clean the site with povidone-iodine or chlorhexidine solution.

• Drape with sterile drapes.

• If burns are particularly painful, give systemic opioid analgesia, such as fentanyl 1 to 2 mcg/kg IV or morphine 0.1 to 0.2 mg/kg IV, then titrated as needed.

• Unsedated patients benefit from local anesthesia of viable tissue at the proximal and distal nonburned edges.

• Loosely pack incisions with sterile gauze impregnated with an appropriate topical antimicrobial such as bacitracin or mupirocin.

• Transfer to a local or regional burn center for coordinated and definitive care, including pain control and tissue perfusion monitoring.

• If a burn center is unavailable, admit to a local hospital.

• Because of edema and shock, skin temperature is a poor indicator of limb ischemia. Use objective measures whenever possible.

• Escharotomy incisions are at risk of infection. Treat incisions as part of the burn wound.

• Do not confuse escharotomy with fasciotomy; escharotomy incisions remain above the fascia.

• Full-thickness burns are insensitive to pain and involve coagulation of superficial vessels, so no anesthesia is needed. However, patients with deep partial-thickness burns may still have pain sensation and require excellent analgesia with IV opioids.

• With proper escharotomy, the incision immediately bulges wide open as the pressure is relieved; failure to demonstrate this indicates the incision was too shallow (or that the eschar was nonconstricting).

1. Heyneman A, Hoeksema H, Vandekerckhove D, et al: The role of silver sulphadiazine in the conservative treatment of partial thickness burn wounds: A systematic review. Burns 42(7):1377–1386, 2016. doi:10.1016/j.burns.2016.03.029

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