Used to decompress accumulated edema under tight, unyielding eschar following full-thickness burn (classic and modern classifications of burns are given in TABLE 74.1)

 Circumferential extremity burn with evidence of neurovascular compromise:

    Cyanosis

    Deep tissue pain

    Progressive paresthesia

    Decreased or absent pulses

    Elevated compartment pressure

    Decreased arterial flow on Doppler ultrasonography

    Pulse oximetry <95% of affected extremity (without systemic hypoxia)

 Thoracic burn with evidence of respiratory compromise due to eschar

 Circumferential neck burn

 Abdominal burn with evidence of increased intra-abdominal pressure (usually estimated by bladder pressure)

 Circumferential penile burn

CONTRAINDICATIONS

 No evidence of tissue hypoperfusion on physical examination

 Normal findings on arterial Doppler ultrasonography

 Adequate respiration despite eschar

 No evidence of increased intra-abdominal pressure

RISK/CONSENT ISSUES

 Often difficult to obtain consent from major burn victims; escharotomy is a life-saving procedure and should be performed even if informed consent from the patient cannot be obtained

 Procedure can cause pain (local and systemic analgesia will be provided)

 Risk of bleeding (minimized with proper technique)

 Whenever the skin is broken, there is potential for introducing infection (sterile technique will be utilized)

LANDMARKS

Escharotomy sites are depicted in FIGURE 74.1.

TECHNIQUE

BURN MANAGEMENT

 First ensure ABC and administer supplemental oxygen

 Strongly consider endotracheal intubation if:

    Burns to the face and neck are present

    Soot in and around the mouth and nose

    Hoarseness, stridor, wheezing, or development of acute coughing

    Carbonaceous sputum

 Give intravenous fluids for resuscitation (for moderate to major burns)

    Use Parkland formula: Ringer lactate 4 mL × weight (kg) × % of total body surface area (TBSA) burned (excluding superficial burns)

       Give ½ of total volume over the first 8 hours from time of burn injury

       Give second ½ of total volume over the following 16 hours

       Titrate to maintain blood pressure and urine output of at least 1 mL/kg/hour

       Continue maintenance fluids in addition

    Place urinary catheter to monitor adequate resuscitation (FIGURE 74.2)

 Provide pain management with frequent pain assessment

    Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS) with or without opioids for superficial burns

    Opioids are necessary for partial-to-full thickness burns

 Administer tetanus prophylaxis

 Wound care, if not delaying transfer to burn unit:

    Use sterile technique

    Clean with mild soap and tap water

    Debride sloughed or necrotic skin; avoid extensive debridement

    Remove ruptured blisters

       Intact blister management is controversial; it is recommended to unroof cloudy blisters or those where rupture is imminent (e.g., over joints)

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