Overview
Definition:
Escharotomy is a surgical procedure involving the incision of the tough, inelastic, and constricting burn eschar (dead tissue) to relieve pressure and restore circulation distal to a circumferential full-thickness or deep partial-thickness burn of a limb or the trunk
It is performed when the eschar impedes venous return or arterial inflow, leading to compromised tissue perfusion.
Epidemiology:
Circumferential burns requiring escharotomy are most common in adults and are associated with significant thermal injuries, often resulting from house fires, industrial accidents, or explosions
The incidence is directly proportional to the severity and depth of the burn
Early recognition and intervention are critical to prevent limb loss and systemic complications.
Clinical Significance:
Circumferential burns can lead to a tourniquet effect, occluding vascular supply and lymphatic drainage
This can cause distal ischemia, compartment syndrome, nerve damage, and ultimately, limb loss if not addressed promptly
Escharotomy is a life-saving and limb-saving intervention that restores perfusion, facilitates wound healing, and improves patient outcomes
It is a core skill tested in surgical examinations.
Clinical Presentation
Signs:
Progressive loss of distal pulses or Doppler signal
Abolished capillary refill in digits
Cyanosis of distal extremities
Paresthesia or anesthesia in the distal nerve distribution
Coldness of the distal limb
Swelling of the distal limb proximal to the burn
Progressive pain disproportionate to the burn injury (suggesting compartment syndrome)
Decreased or absent motor function distally.
Diagnostic Criteria:
The diagnosis is primarily clinical, based on the presence of a circumferential deep burn and evidence of compromised distal perfusion
There are no specific laboratory tests
however, a surgical consultation is indicated for any circumferential full-thickness burn of a limb or over a major joint to assess for the need of escharotomy
Continuous monitoring of distal pulses and tissue oxygenation (e.g., using continuous pulse oximetry if available) is crucial.
Indications
Absolute Indications:
Documented loss of distal pulses (palpable or Dopplerable)
Evidence of compartment syndrome in a limb with a circumferential burn
Complete absence of capillary refill in digits with circumferential burn
Cyanosis of distal extremities with circumferential burn.
Relative Indications:
Progressive paresthesia or loss of sensation distal to the burn
Progressive edema proximal to the burn
Circumferential chest burns compromising respiration
Significant pain disproportionate to the burn wound
Suspicion of compromised venous outflow from the extremity.
Surgical Management
Procedure Steps:
The escharotomy is typically performed in an operating room or dedicated burn resuscitation area under adequate analgesia and/or sedation
The patient is positioned to best visualize the burn
Incisions are made along the long axis of the limb, extending through the entire thickness of the eschar, from healthy tissue proximal to the burn to healthy tissue distal to the burn
For limbs, typically two incisions are made, one ulnar and one radial for an upper extremity, and one medial and one lateral for a lower extremity, to avoid major nerves and vessels
For the trunk, incisions should be placed longitudinally along the mid-axillary line bilaterally if circumferentially involved
Adequate hemostasis is achieved
The wound is then dressed with appropriate burn dressings
Visualization of bleeding from small vessels within the eschar during incision confirms adequate depth and release of constricting pressure.
Instrumentation:
Scalpel (e.g., #10 or #15 blade)
Electrocautery for hemostasis
Doppler ultrasound for pulse assessment (pre and post-procedure)
Burn dressings
Local anesthetic (e.g., lidocaine) for local infiltration if sedation is not used.
Anesthesia And Analgesia:
Local anesthesia with lidocaine can be used for smaller escharotomies or in awake patients
For larger or more painful procedures, procedural sedation or general anesthesia may be required
Adequate systemic analgesia is paramount both pre- and post-procedure.
Postoperative Care
Wound Care:
Wounds are dressed with sterile gauze and a conforming bandage
Dressings are typically changed daily or as needed
Topical antimicrobial agents may be applied
Monitoring for signs of infection is crucial.
Monitoring:
Close monitoring of distal pulses (palpable or Dopplerable), capillary refill, sensation, and motor function is essential post-operatively
Continuous pulse oximetry can be helpful
Vital signs and urine output should be monitored for evidence of adequate resuscitation and perfusion.
Pain Management:
Aggressive pain management with opioids and adjunctive agents is necessary due to the severe nature of burns and the pain associated with escharotomy and subsequent wound care.
Complications
Early Complications:
Hemorrhage from the escharotomy incisions (especially from deeper venous or arterial injury)
Infection of the escharotomy wounds
Damage to underlying nerves or vessels if incisions are poorly placed
Inadequate decompression leading to continued ischemia
Conversion to a full-thickness graft if the burn is deeper than initially assessed.
Late Complications:
Scarring and contracture formation at the escharotomy sites
Persistent nerve deficits
Delayed wound healing
Malunion of fractures if present
Chronic pain.
Prevention Strategies:
Careful anatomical landmark identification before incision
Using Doppler to confirm pulse presence and extent of occlusion
Making incisions only through the eschar, not into viable tissue unless necessary
Ensuring adequate analgesia and sedation
Prompt surgical consultation for circumferential burns.
Key Points
Exam Focus:
Escharotomy is indicated for circumferential deep burns causing vascular compromise
Incisions are made longitudinally through the eschar
Location of incisions for limbs and trunk is critical
Post-operative monitoring of distal perfusion is paramount
Differentiate escharotomy from fasciotomy (for compartment syndrome within muscle compartments).
Clinical Pearls:
Always assess distal pulses and capillary refill in circumferential burns
If in doubt, a Doppler can confirm absence of flow
Remember to incise through the eschar only, not deep into muscle
Bleeding from the incision confirms adequate decompression
Chest escharotomies may be needed for circumferential torso burns affecting respiration.
Common Mistakes:
Delaying escharotomy until irreversible ischemia has occurred
Making incisions too shallow or too deep
Not adequately assessing distal pulses pre- and post-procedure
Performing escharotomy for superficial burns
Confusing escharotomy with fasciotomy.