Show notes
Escharotomy involves incision of inelastic burned tissue (eschar) that can impair perfusion of the extremities, as well as restrict chest wall movement and ventilation.Indications:Limb hypoperfusionVentilation restrictionLimb HypoperfusionCan occur with circumferential AND non-circumferential burns.Note: There is insufficient evidence to support any specific standard, or test, to aid the clinician in deciding whether an escharotomy is needed.Traditionally, the decision to perform an escharotomy has been based on the following clinical signs:Reduced skin temperatureDecreased capillary refill timeReduced/absent pulses (very late sign)Complaints of deep aching pain, progressive loss of sensation or paraesthesia (these parameters are difficult to assess in a severely burned, sedated or mechanically ventilated patient)Clinical assessment of skin temperature and pulses may be unreliable indicators of perfusion due to peripheral vasoconstriction and local oedema. Conversely, peripheral pulses may be palpable despite severe underlying muscle ischaemia.Most escharotomy decisions are, however, made on the clinical assessment of the burn size, site and depth, and indeed in burns centres, may be performed prophylactically.The following objective signs can also be used to aid decision making*:Doppler - Repeated measurements may be necessary and progressive reduction in flow likely warrants action. Absence of arterial flow is an immediate indication for escharotomy.Compartmental pressures - Pressure of > 40mmHg warrants immediate escharotomy. Consider for pressures between 25-40mmHg with other clinical features of hypoperfusion.Pulse oximetry - Saturation of < 95% in circumferentially burned extremity warrants consideration of escharotomy (in the absence of systemic hypoxia).*Please note: there is little evidence to support the use and interpretation of the following aids and, in fact, they are rarely performed by burns specialists. However, on occasion they may help the inexperienced provider in decision making:Ventilation RestrictionCan present with circumferential AND non-circumferential burnsChest or upper abdominal burns can impair respirationThe following objective signs can also be used to aid decision making:Persistent arterial hypercapnia in mechanically ventilated patientsElevated peak inspiratory pressuresPaediatric patients: predominant diaphragmatic breathing, so even non-circumferential burns, limited to anterior chest and abdomen, may require escharotomyContraindications:No specific contraindications. If the chance of survival is deemed to be very low the decision to proceed should be carefully considered.Join us at The Procedures Course in Melbourne to practice this and other life and limb saving procedures. Podcast »Subscribe: iTunes | Android | RSS Further reading »Kupas DF, Miller DD. Out-of-Hospital Chest Escharotomy: A Case Series and Procedure Review. Prehospital Emergency Care (2010) 14:3, 349-354Darton A, ACI Clinical Practice Guidelines - Escharotomy For Burns Patients - NSW Statewide Burn Injury Service, Agency for Clinical Innovation, August 2011Victorian Burns Guideline - Early Management - EscharotomyVictorian Burns Guideline - Initial Management & Secondary surveyWheeless Online Textbook of Orthopaedics - EscharotomyNew Zealand National Burn Service, Escharotomy Guideline (2014).Hettiaratchy S, Papini R. Initial management of a major burn: II – assessment and resuscitation. BMJ 2004; 329;101–3.Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. J Burn Care Res 2009;30:759-68.Saffle J. Practice guidelines for burn care. Boston, MA: American Burn Association; 2001.Moylan JA Jr, Inge WW Jr, Pruitt BA Jr. Circulatory changes following circumferential extremity burns evaluated by the ultrasonic flowmeter: an analysis of 60 thermally injured limbs. J Trauma 1971;11:763-70.Bardakjian VB, Kenney JG, Edgerton ML, et al. Pulse oximetry for vascular monitoring in burned upper extremities. J Burn Care Rehabil. 1988;9:63.
