5. Escharotomy

CPT Daniel J. Stinner, M.D.

I. Introduction (see figure 3)

            A. Typically performed at bedside under sterile condition with IV sedation using electrocautery

            B. Can also be performed in operating room if immediate access available

            C. Electrocautery has added benefit of haemostatic control, but if unavailable, scalpel can be used

            D. General principle

                        1. to make surgical incisions through burned eschar to allow expansion of underlying tissues

                        2. if perfusion does not return following escharotomy, fasciotomies are indicated

            E. Escharotomy ≠ fascitotomy – escharotomies are not same as fasciotomies and sometimes fasciotomy must also be performed

II. Indication for escharotomy: ischemia

            A. Progressive flow reduction by Doppler ultrasound – primary indication for escharotomy (when evaluating upper extremities, Doppler ultrasound the palmar arch, not the wrist, i.e., evaluate distally)

            B. Decreased capillary refill (less than 2 seconds)

            C. Cyanosis

            D. Relentless deep pain progressing to numbness

III. Chest escharotomy

            A. In circumferential chest burns, chest wall expansion may be restricted, resulting in decreased ventilation

            B. Chest escharotomy can be performed to improve ventilation

                        1. lateral incisions are made on both sides of chest

                        2. these incisions are connected via transverse or inverted V-shaped incision just below costal margin

                        3. goal is to separate thorax from abdomen effectively and improve chest wall expansion (see figure 4)

IV. Extremity escharotomy

            A. Full-thickness incisions along medial and lateral midaxial lines should be made (see figure 5), ideally, escharotomy incisions performed through same skin incisions that could be used later for fasciotomies, if indicated (see figure 6)

            B. Escharotomies should be carried to just beyond the area of full-thickness burn

                        1. when in doubt, make incision longer rather than shorter because burns tend to evolve during period immediately following the burn

                        2. special considerations for upper extremity escharotomies

                                    a. know your anatomy – watch for superficial structures

                                                i. at level of wrist, watch for superficial branch of radial nerve along radial side of wrist

                                                ii. at level of elbow, watch for ulnar nerve at level of medial epicondyle

                                    b. digital escharotomies can be performed along midaxial line between neurovascular bundle and extensor apparatus; the ideal side to perform escharotomy allows for preservation of pinch

                                                i. thumb – radial incision

                                                ii. index finger, middle finger, ring finger, small finger – ulnar incisions

                                    c. hand escharotomies can be performed over the index finger metacarpal and ring finger metacarpal; if this release is inadequate, incisions can be converted to fasciotomies (see hand fasciotomies section)

                                    d. carpal tunnel releases may also be required to achieve adequate decompression of hand

                        3. children more prone to compartment syndromes and distal tip necrosis due to smaller cross-sectional area, but performing digital escharotomies in children remains controversial

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense or the U.S. Government.