Burns 102: Escharotomy for 3rd Degree (Full-Thickness) Burns Video Lecture | Introduction to Burn Care: Medical Treatment - Health & Fitness

in contrast to more superficial injuries
third-degree burns have a leathery
eschar that prevents skin and underlying
soft tissue from swelling non-compliant
skin and circumferential third-degree
burns can create a tourniquet like
effect on the trunk or extremities
during resuscitation fluid third spacing
will increase tissue pressure cause
vascular compromise and ultimately lead
to irreversible ischemia escharotomy to
prevent compartment syndrome can be limb
and life-saving a simple analogy to
remember is that circumferential
third-degree burns function like casts
that is too tight escharotomy is akin to
by valving the cast to relieve the
constriction consider escharotomy for
circumferential third-degree burns on
extremities in torso during the first 24
to 48 hours post injury when trans
capillary leak and fluid needs are
greatest circumferential burns on the
torso can restrict chest excursion and
lead to abdominal compartment syndrome
abdominal and chest escharotomy x'
prevent hemodynamic and pulmonary
compromise in this situation in general
we do not advise pre-hospital personnel
or physicians at referring facilities to
perform prophylactic escharotomy
especially if the patient can be
transported to a specialized Burn Center
within 12 hours increased tissue
pressures typically will not occur until
administer fluids gradually third space
into injured areas physical examination
is critical to determine adequate limb
perfusion detect elevated abdominal
compartment pressures or any restriction
to chest excursion perform a
neurovascular examination including
distal pulses and sensory and motor exam
on initial evaluation we recommend
hourly reassessment in the intensive
care unit in the first 24 to 48 hours
elevate circumferentially burned
extremities above the level of the heart
in an effort to improve venous and
lymphatic return be careful to avoid
constrictive dressings and blood
pressure cuffs as they will exacerbate
swelling in the effective extremity
extremities that require escharotomy are
typically tends to touch with the
patient reporting severe pain and
paresthesias symptoms however may be
masked by analgesics and sedatives
particularly when a patient is on
mechanical ventilator
thus palpation of the affected extremity
is
extremely important weak or absent
pulses motor weakness or cool or cold
distal extremities are late signs of
compartment syndrome that escharotomy
helps avoid routine measurements of
compartment pressures are not necessary
when direct palpation of the affected
area reveals a tense abdomen or
extremity restriction of chest excursion
may present as elevated peak inspiratory
and end expiratory pressures hypercarbia
and difficulty ventilating there are
however two instances where direct
pressure measurements can be useful
adjunct number one when physical
examination is equivocal and the
patient's response is limited because of
sedation or altered mental status or
number two when the extremity remains
tense after eschar release suggesting
the need for underlying fascial
compartment release a procedure known as
fasciotomy this latter scenario is more
common in cases of electrical injury or
combined burns and trauma measure
compartment pressure is either with an
18 gauge needle attached to an arterial
pressure transducer or using a
commercially available device bladder
pressures are good surrogate
measurements of the intra-abdominal
compartment pressure obtain informed
consent when possible although implied
consent is often used in intubated
patients without available surrogates it
is a common misconception that incisions
into leathery third-degree burns do not
cause significant pain escharotomy can
be a painful procedure local anesthetics
are impractical when the total length of
skin incisions mandates larger local
anesthetic doses than can be safely
administered we recommend minimal to
moderate sedation with monitoring on
spontaneously breathing patients whereas
intubated patients receive gradual
titration of intravenous pain and
sedation medications during the
procedure
escharotomy is a clean procedure and
does not require an operating room or
sterile environment cleanse the skin
with chlorhexidine gluconate or
povidone-iodine and isolate the
procedure sites with sterile towels or
sheets where sterile gloves
we recommend using electro pottery
rather than scalpel to avoid troublesome
bleeding
remember that escharotomy incisions only
extend along the areas of third-degree
burns do not incise into more
superficial burns or spared skin areas
incised through the eschar to visualize
subcutaneous fat expansion of the
underlying soft tissue is proof of
release in this example the restricted
area causes an hourglass appearance that
disappears upon complete release obtain
hemostasis of subdermal vessels by a
quick tap of the Bovie electric cautery
the underlying fat often opens by one
centimeter or more indicating that
escharotomy was beneficial at that
location once released continued
division of the deeper fat is not
beneficial
extremities make separate incisions
along the medial and lateral aspect of
an extremity
chest and abdomen make an incision along
the anterior axillary lines bilaterally
from the clavicle to the costal margin
with extension down to the hip level for
abdominal release in many patients
lateral incisions alone do not afford
sufficient release in those situations
transverse incisions across the costal
margin the clavicle area and below the
umbilicus are often necessary hands and
feet place incisions on the dorsum of
the hand between the metacarpal bones
similarly for the feet place incisions
on the dorsum between the metatarsal
bones if the third degree also involves
the proximal extremity be sure to
connect the most medial and lateral
incisions to the respective longitudinal
extremity incision never place an
escharotomy incision on palm or sole do
not perform escharotomy
on specialty areas such as neck fingers
toes and genitalia this procedure is
seldom necessary for these areas and can
create permanent harm have done
improperly when considering need for
escharotomy in specialty areas consult
the nearest burn center immediately
escharotomy sites are treated the same
as the adjacent burn
we recommend silver sulfadiazine also
known as silvadene for third-degree
burns continue serial examinations to
ensure adequate decompression persistent
pain contracted extremities and pigment
and urine suggests inadequate release
reassessment and additional
decompression may prevent permanent
neurologic injury and amputation non
circumferential third-degree burns a
common misconception is that a burn must
be circumferential to warrant
escharotomy release in cases of very
deep third-degree burns
for example flame or contact injury the
eschar will cause the skin to shrink
from all directions
these non circumferential burns
sometimes do not sufficiently respond to
elevation and require release to relieve
pain and pressure
skip incisions in this example areas
that were not incised or still
constrictive incisions that are too deep
avoid and sizing through the fat layer
down to the fashio this fat does not
require a release with a divot created
in the fat subsequent skin grafting
often results in a poor aesthetic result
full thickness circumferential burns
prohibit expansion of underlying soft
tissues with ongoing resuscitation and
third spacing of fluids longitudinal
incisions through the Esk are released
the underlying subcutaneous fat and
prevent impending limb ischemia or
cardiopulmonary compromised in certain
potential burns of the torso continued
serial examinations are critical to
document and guide to continued therapy