Overview
Definition:
Escharotomy is a surgical procedure involving linear or longitudinal incision through the full thickness of an eschar (the devitalized, inelastic burn tissue) down to the subcutaneous fat or to the level of superficial fascia
It is performed to relieve pressure in circumferential deep burns that impair circulation or respiration.
Epidemiology:
Deep circumferential burns requiring escharotomy occur in a significant percentage of patients with severe burns, particularly those involving limbs, the trunk, or the neck
Incidence varies based on burn etiology, depth, and extent, but is a critical consideration in burn centers.
Clinical Significance:
Failure to perform timely escharotomy in cases of circumferential deep burns can lead to devastating consequences, including compartment syndrome, distal ischemia, limb loss, respiratory compromise, and severe functional deficits due to contracture formation
Early recognition and intervention are paramount for salvaging tissue and function.
Indications
Absolute Indications:
Circumferential full-thickness or deep partial-thickness burns of the extremities or torso with evidence of compromised circulation or respiration
Signs include: absent or diminished distal pulses, cool extremities, prolonged capillary refill (>2 seconds), paresthesia, motor deficits, or decreased tidal volume in chest/abdominal burns.
Relative Indications:
Emergent need for improved ventilation in chest burns, even without overt circulatory compromise
Development of a tense, inelastic eschar over a joint that may impede range of motion
Prophylactic escharotomy may be considered in select cases with extensive circumferential burns without immediate signs of compromise but with high risk.
Contraindications:
There are very few absolute contraindications
Relative contraindications may include superficial burns with no inelasticity or compromise, or coagulopathy where bleeding risk outweighs benefit
The decision is always based on a risk-benefit analysis.
Preoperative Preparation
Assessment:
Thorough assessment of burn depth, extent, and location
Evaluation of distal perfusion (Doppler ultrasound if pulses are impalpable), sensation, and motor function
Assessment of respiratory effort in thoracic burns
Document all findings meticulously.
Patient Stabilization:
Ensure hemodynamic stability
Adequate intravenous fluid resuscitation is crucial
Pain management with appropriate analgesics
Administration of tetanus prophylaxis and appropriate antibiotics if indicated.
Anesthesia And Positioning:
Escharotomy is typically performed under local anesthesia with sedation for conscious patients, or general anesthesia for deeply sedated or intubated patients
Positioning should allow optimal access to the burn area
For limb escharotomies, the limb should be elevated to reduce edema.
Procedure Steps
Marking Incisions:
Incisions should be placed along the mid-axillary line or mid-clavicular line for thoracic burns, and along the long axis of the limb for extremity burns
Avoid major superficial nerves and vessels
The incision should extend from the proximal to the distal limit of the constricting eschar.
Incision Technique:
Use a scalpel or electrocautery to make a full-thickness incision through the eschar
The incision should extend until the eschar visibly separates, or until pulsatile bleeding is encountered from the subcutaneous tissue, indicating release of constriction
For limbs, two incisions may be necessary (medial and lateral) if the burn is circumferential.
Release And Hemostasis:
Once the incision is made, the eschar will gape, releasing the constricting pressure
Minimal bleeding from the subcutaneous tissue is expected and usually stops spontaneously or with gentle pressure
If significant arterial bleeding occurs, it must be controlled with sutures or cautery
Inspect the wound for adequate release of tension.
Dressing:
The wounds are then dressed with sterile, non-adherent dressings, followed by absorbent layers and an elastic bandage to manage potential oozing and edema
The extremity should be elevated to promote venous return and reduce swelling
Regular monitoring of distal perfusion and sensation is essential post-procedure.
Postoperative Care
Monitoring:
Close monitoring of distal pulses (by palpation or Doppler), capillary refill, skin color, temperature, sensation, and motor function is critical
Continuous monitoring of respiratory status is necessary for thoracic escharotomies
Vital signs should be checked frequently.
Wound Care:
Daily wound care with sterile dressings
Application of topical antimicrobial agents as per burn center protocol
Prevention of infection is a high priority
Pain management should be continued.
Fluid Management:
Adequate fluid resuscitation must be maintained, as escharotomy can lead to increased fluid loss from the wound bed.
Rehabilitation:
Early initiation of physical and occupational therapy is vital to maintain range of motion and prevent contractures
Splinting may be required to maintain optimal limb position and prevent deformities.
Complications
Early Complications:
Hemorrhage from incised vessels
Infection of the escharotomy site
Damage to underlying nerves or tendons
Inadequate decompression leading to persistent ischemia
Over-exuberant bleeding from the subcutaneous plane.
Late Complications:
Scarring and contracture formation at the incision sites
Nerve injury leading to chronic pain or sensory deficits
Functional impairment if not adequately treated with rehabilitation
Hypertrophic scarring and keloid formation.
Prevention Strategies:
Meticulous surgical technique, including accurate marking and careful incision placement, avoiding major structures
Prompt identification of indications
Adequate post-operative monitoring and timely intervention
Aggressive wound care and rehabilitation.
Key Points
Exam Focus:
Understanding the indications for escharotomy, distinguishing between escharotomy and fasciotomy, and recognizing the signs of circulatory compromise in circumferential burns are high-yield for DNB and NEET SS exams.
Clinical Pearls:
Always confirm the presence of inelasticity of the eschar
Use Doppler to assess distal pulses if not palpable
Remember that subcutaneous bleeding after incision is normal and expected
pulsatile bleeding indicates a deeper vessel injury.
Common Mistakes:
Delaying the procedure until irreversible damage has occurred
Performing incisions that are too shallow or too short
Failing to adequately monitor distal perfusion post-operatively
Confusing escharotomy with fasciotomy for compartment syndrome.