ESCHAROTOMY

ESCHAROTOMY
Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). * y is a surgical procedure used to treat full thickness (thirddegree) circumferential burns. y the surgical division of the nonviable eschar, will allow the cutaneous envelope to become more compliant. *
y

COMPARTMENT SYNDROME
y

is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits.* Edema formation in the tissues under the tight, unyielding eschar of a circumferential burn on an extremity may produce significant vascular compromise.*

y

Thoracic Escharotomy

INDICATIONS are the presence of a circumferential eschar with one of the following: 1. Doppler signals. pulse oximetry. decrease in Doppler signal. and sensation distal to the burned area should be checked every hour.* Subsequently. any increase in capillary refill time. Impending or established vascular compromise of the extremities or digits Impending or established respiratory compromise due to circumferential torso burns[6] o o Capillary refilling time. 2. . or change in sensation should lead to rechecking the compartment pressures.

pressures greater than 30 mmHg or below 30 mmHg diastolic are frequently cited. Although controversial.* . Compartment Pressure y is measured by inserting an arterial line into the compartment and recording the pressure.

MAKING ALGORYTHM .DECISION.

CONTRAINDICATIONS Patients who have established irreversible gangrene of the extremity or digit in association with a circumferential or near-circumferential eschar would not likely benefit from an escharotomy. This scenario is likely to be encountered in patients who have been managed nonoperatively for a prolonged period of time. during which the neurovascular status of the extremity involved was not monitored adequately. In this group of patients. [9] . the risks and potential complications of performing an escharotomy are to be weighed carefully against the benefits.

ANESTHESIA *Patient who is obtunded and intubated. to allow the procedure to be completed adequately. . general anesthesia. Patients who are awake or conscious require sedation and. occasionally. no anesthesia is required because the eschar is nonviable tissue with complete destruction of nerve endings.

EQUIPMENT Sterile drapes solution Povidone-iodine Electrocautery* Dressing materials .

Maintain the ability to move the patient into lateral positions to allow circumferential access to the extremity or torso.POSITIONING Position the patient supine. as needed. .

PROCEDURE & TECHNIQUE .

y Compartment pressures can be obtained intraoperatively after completion of the escharotomy. Severely burned limbs may require performance of fasciotomy concomitantly with the escharotomy. 2. Clean the proposed surgical site with povidoneiodine solution and drape with sterile drapes.1. y This may be determined preoperatively by measurement of compartment pressures greater than 30 mm Hg. Use electrocautery to create incisions in the eschar up to the level of the subcutaneous fat. 3. . If elevation of pressure above 30 mm Hg is persistent. a fasciotomy should be performed.

4. 6. An immediate release in tissue pressure is experienced as a discernible popping sensation. Carry the incision of the eschar down through to the level of the subcutaneous fat. . and the incisions should extend across joints to allow for decompression of neurovascular structures. 5. Carry the incisions approximately 1 cm proximal and distal to the extent of the burn. Areas overlying joints have densely adherent skin.

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neck. and digits. . Make escharotomy incisions for the chest. limbs.7.

y Persistent low Doppler signals or elevated compartment pressures indicate inadequate release of tissue pressure and a need for additional escharotomy incisions and. as the burn wound. using a handheld Doppler. y Improvement in flow and decrease in compartment pressures indicate that the procedure is adequate. the addition of fasciotomy. possibly. Adequacy of the escharotomy can be tested after completion by checking capillary filling pressures. and by checking compartment pressures. . The resulting wounds are a potential source of infection and should be treated. Bleeding from escharotomy incisions should be controlled by use of the electrocautery. with application of topical antimicrobial and dressings.

renal failure. They include the following: y y y y y y Muscle necrosis Nerve injury Gangrene resulting in amputation of the limb or digits Respiratory compromise due to inadequate ventilation as a result of compressive effect of chest and upper torso burns Abdominal compartment syndrome with visceral hypoperfusion as a result of abdominal wall and upper torso burns Systemic complications of inadequate decompression including myoglobinuria.COMPLICATIONS Complications of inadequate decompressionor of not performing an escharotomy when indicated are severe. hyperkalemia. and metabolic acidosis .

Complications of an escharotomy are as follows: Excessive blood loss Inadvertent fasciotomy: This results in exposure of the underlying viable tissue. especially in the extremities and digits . Incision/injury to the underlying healthy tissue including neurovascular structures. which can become desiccated.

These wounds also contribute to the ongoing insensate fluid losses in a manner similar to the burns wounds. . the escharotomy should be performed under antibiotic coverage. and the manipulation can result in bacteremia and septic shock. Infection of the open escharotomy wounds: These wounds are treated with the same degree of care (with dressings and application of antimicrobial agents) as the burns wounds. Bacteremia: Underlying tissue may be infected. If underlying infection is suspected.

FASCIOTOMY .

* .FASCIOTOMY is a surgical procedure where the fascia is cut to relieve tension or pressure (and treat the resulting loss of circulation to an area of tissue or muscle. Compartment syndrome results from the combination of increased interstitial tissue pressure and the noncompliant nature of the fascia and osseous structures that make up a fascial compartment.* It is a clinical procedure indicated once the clinical diagnosis of compartment syndrome is made.

pressure increases within the closed system causing microvascular compromise and subsequent muscle and nerve ischemia.* Diagnosis of compartment syndrome can be made by clinical examination or with more objective measures such as compartment pressures. Without sufficient compliance of these structures. Fascial compartments y are unforgiving connective tissue septa and osseous structures. A high clinical suspicion for compartment syndrome along with serial examinations without the use of compartment pressure measurements is also used .

Pain that is out of proportion to clinical findings Pain with passive stretch of involved muscles Pain with palpation of involved compartment Pressure increase within the compartment as measured . 2. Four signs and symptoms are commonly referred to as the 4 P's. 3.INDICATIONS Indications for surgical intervention in acute compartment syndrome in the alert patient are generally based on clinical impression. 4. as follows: 1.

OTHER INDICATIONS People who are likely to suffer injuries needing a fasciotomy include the following: y Victims of vehicular accidents or crush injuries Athletes who have sustained one or more serious impact injuries People with severe burns Persons who are severely overweight y y y .

CONTRAINDICATIONS Fasciotomy is contraindicated when diagnosis of compartment syndrome is made late. Fasciotomy 3-4 days after onset of compartment syndrome can lead to infection and kidney failure in a setting of devascularized and necrotic muscle .

* . [4] This cycle propagates itself and cell death ² induced metabolic changes contribute to the hypoxia. causing further increase in intracompartmental pressures. venous outflow is halted. This results in a shunting of blood flow away from the injury and toward areas of lower vascular resistance.PATHOPHYSIOLOGY Interstitial pressures increase within a compartment and. as it reaches and exceeds venous pressure. further increasing pressure.

General .ANESTHESIA Anesthesia decision making differs based on the situation in which the compartment syndrome and fasciotomy occur. anesthesia is often performed when the situation allows.

EQUIPMENT Sterile gloves Sterile drapes Soft tissue retractors Scalpel Dissecting scissors Electrocautery Wound V. or bulky dressings .C.A.

return to OR for excision of necrotic muscle. Perform dressing changes at bedside or in OR as deemed appropriate per clinical situation. If delayed primary skin closure cannot be performed within 5 days. perform splitthickness skin grafting.POST-PROCEDURE Elevate affected extremity for 24-48 hours after surgery. Perform delayed primary skin closure when swelling subsides. . If necrotic muscle develops.

C. Perform standard suture or staple removal and postoperative wound checks. Negative pressure wound therapy (wound V. Overall.A.) may be used instead of bulky dressing . the rehabilitation protocol is dependent upon the underlying injury that caused the compartment syndrome and need for fasciotomy.

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