Strongly Consider Escharotomy in Circumferential Burns
Richard Wong She MBChB
James H. Holmes IV MD
Eschar refers to relatively inelastic burned skin. An escharotomy is the procedure of “opening the eschar,” either to restore or improve the perfusion to an extremity or to allow or improve ventilation when the torso is involved. Inflammatory mediators released in response to the burn injury, in combination with fluid resuscitation, result in generalized edema and third spacing. Unburned skin is elastic and can accommodate this increased soft tissue volume, whereas burned skin, particularly when the burn is a deep partial-thickness or full-thickness burn, is relatively inelastic and cannot. Thus, with time, ongoing tissue edema and swelling beneath the inelastic burn eschar results in decreased tissue perfusion and tissue compliance. Recognition of this evolving clinical situation requires a high index of suspicion and ongoing clinical assessment. The clinical manifestations of constricting eschar that mandate release depend on the site of involvement.
Extremities
In the extremities, the signs and symptoms are similar to those of compartment syndrome (which mandates fasciotomy) and are described by the well-known “p’s”: pain out of proportion, pain on passive flexion/ extension, perishingly cold, palpably swollen, pallor, paresthesia, and pulselessness. Actual loss of a pulse is a late sign, whereas a diminished signal on Doppler exam is the hallmark. Treatment involves the release of the constricting, or rather limiting, envelope of tissue (the eschar).
The index of suspicion for the need for escharotomy should be raised in the patient who requires large fluid volumes for resuscitation because of the size of his or her burn and in the patient with a circumferential or near-circumferential deep partial-thickness or full-thickness burn. In this setting, clinical monitoring consists of assessment of capillary refill and pulses (either through palpation or Doppler ultrasound). Any change in the clinical examination suggestive of circulatory compromise should be investigated. Reversible causes of poor perfusion, namely hypothermia, hypovolemia, hypotension, and
external causes of constriction (e.g., dressings) should be addressed. If poor perfusion remains, then escharotomy should be performed in the affected limb.
external causes of constriction (e.g., dressings) should be addressed. If poor perfusion remains, then escharotomy should be performed in the affected limb.
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