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Burns - Escharotomy

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This procedure is rarely performed by emergency physicians

Every effort should be made to discuss the case and procedure with a burn’s unit prior to intervention

Indications

Full-thickness circumferential burns in the extremities and thorax

and

Respiratory or circulatory compromise (central or extremity saturations <95%)

Contraindications (absolute in bold)

Emergency airway management required

Haemodynamic instability requiring resuscitation

Alternatives

Limb elevation

Oxygenation and ventilation

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Failure to decompress

Bleeding

Damage to underlying structures (ulnar nerve, common fibular nerve)

Infection

Procedural hygiene

Standard precautions

Surgical aseptic non-touch technique

PPE:sterile gloves, surgical gown, surgical mask, protective eyewear or face shield

Area

Resuscitation bay

Staff

Procedural clinician and assistant

Equipment

Skin marker

Scalpel

Moist dressings: alginate (Algicide or Kaltostat) or impregnated gauze (Bactigras)

Crepe bandages

Positioning

Intubated and ventilated

Supine in anatomical position

Medication

Cephazolin 2g IV pre-procedure

Sedation and intravenous pain relief post intubation

Sequence (extremity escharotomy)

Mark mid-axial lines bilaterally with skin marker (between flexor and extensor surfaces)

At the elbow and knee mark anterior to mid-axial line to avoid ulnar and common peroneal nerves

Incise along the marked lines avoiding flexural creases (elevated risk of neurovascular injury)

Always start and finish the incision one centimetre into unburned healthy tissue

Incise full skin thickness into subcutaneous fat (but not muscle) seeing obvious separation of wound edges

Running a finger along the incision will detect residual restrictive areas

Sequence (chest escharotomy)

Mark mid-axillary line with skin marker over chest (between flexor and extensor surfaces)

Mark a transverse elliptical line across the abdomen below the costal margin

Incise along the mid-axillary lines

Incise along the transverse elliptical line to join the vertical incisions

Always start and finish the incision one centimetre into unburned healthy tissue

Incise full skin thickness into subcutaneous fat (but not muscle) seeing obvious separation of wound edges

Running a finger along the incision will detect residual restrictive areas

Post-procedure care

Ensure the adequacy of the incisions by reassessing the circulation or respiration

Dress with alginate (Algicide or Kaltostat) or impregnated gauze (Bactigras) in escharotomy wound

Dress with loose crepe as outer dressing

Elevate limbs and monitor extremity saturations (limb escharotomy)

Monitor respiration and ventilatory pressure (chest escharotomy)

Continue burn care in discussion with regional burns centre

Document procedure (completion, technique, complications)

Tips

This distressing and painful procedure is best performed after intubation and IV pain relief

Escharotomy is important at joints due to high tension at these sites (avoiding neurovascular structures)

All third degree burns will require debridement and skin grafting (removing escharotomies)

Discussion

Escharotomy should be performed when respiratory function (chest) or circulation (extremity) is compromised. This is best achieved by an experienced surgeon in an operating theatre. Occasionally, with severe burns this may occur early during the resuscitation period requiring escharotomy in the emergency department or during transport.

Clinical assessment of compartment syndrome may be difficult as signs such as capillary refill and pain may not be assessable. The available evidence suggests that pulse oximetry detects changes in oxygen levels early before the clinical signs appear. Oxygen saturation below 95% may be used to guide when to perform escharotomy, both due to ventilation restriction and extremity circulatory compromise. In these cases, escharotomy promotes prompt return of saturations to normal values.

Most articles propose eschar be divided by incisions down the long axis of the limb in midmedial or midlateral lines through the dermis to fat or down to deep fascia, taking care to avoid damaging any important underlying structures, particularly nerves. We recommend moving the incision anterior at joints to avoid such structures (ulnar nerve, common fibular nerve). The key point is to avoid these structures and complete the incision, the actual path of the incision is less relevant. Any incision will decompress the limb.

Prophylactic antibiotics may have value in severe burns, we recommend their use in escharotomy.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

ACI State-wide Burn Injury Service

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Agency for Clinical Innovation. Escharotomy for burn patients. 2nd ed. Sydney: ACI; 2019. 7pp. Available from: https://www.aci.health.nsw.gov.au/networks/burn-injury/resources

New Zealand National Burn Service. Escharotomy guidelines. Auckland (NZ): New Zealand National Burn Service; n.d. 2pp. Available from: http://www.nationalburnservice.co.nz/policies-and-guidelines/

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Rice PL, Orgill DP. Emergency care of moderate and severe thermal burns in adults. In UpToDate. Waltham (MA): UpToDate; 2019 Oct. Available from: https://www.uptodate.com/contents/emergency-care-of-moderate-and-severe-thermal-burns-in-adults

de Barros MEPM, Coltro PS, Hetem CMC, Vilalva KH, Farina JA Jr. Revisiting escharotomy in patients with burns in extremities. J Burn Care Res. 2017;38(4):e691-e698. doi:10.1097/BCR.0000000000000476

Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. J Burn Care Res. 2009;30(5):759-768. doi:10.1097/BCR.0b013e3181b47cd3

Bardakjian VB, Kenney JG, Edgerton MT, Morgan RF. Pulse oximetry for vascular monitoring in burned upper extremities. J Burn Care Rehabil. 1988;9(1):63-65. doi:10.1097/00004630-198801000-00015

Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, Solà I, Bonfill Cosp X. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev. 2013;(6):CD008738. Published 2013 Jun 6. doi:10.1002/14651858.CD008738.pub2

Tagami T, Matsui H, Fushimi K, Yasunaga H. Prophylactic antibiotics may improve outcome in patients with severe burns requiring mechanical ventilation: propensity score analysis of a Japanese nationwide database. Clin Infect Dis. 2016;62(1):60-66. doi:10.1093/cid/civ763

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