POTD: Escharotomy

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This POTD is inspired by a rosh review question I got wrong recently. This rare ED procedure is important to understand but not that common so here’s a refresher!


What is an escharotomy?

  • Eschar is dried dead skin/tissue after a burn or infection (shown above)

  • An escharotomy involves incising through burnt skin to release eschar 

Why perform it?

  • Circumferential, full-thickness (sometimes partial thickness) burns that produce a splinting/tourniquet effect that could impair limb circulation or respiratory muscle movement

  • Eschar is stiffer than skin -- restricts movement

  • Also with fluid resuscitation and local edema, increased risk of increased compartment pressures when fluid builds up beneath eschar

Some physical exam findings that suggest need for escharotomy:

  • Limbs with the 6 P’s: 

    • Pain, paresthesias, poikilothermia, pallor, paresis, absent pulse

  • O2 sat < 95%

  • Decreased/absent doppler signal in affected limb

  • High compartment pressure

  • Any compromise in respiratory function or hemodynamics

Equipment

  • Local anesthetic +/- sedation

  • Sterile prep and drapes

  • Scalpel

  • Marking pen

  • Cautery device

Positioning

  • Supine

  • Upper limbs supinated

  • Lower limbs in neutral position

  • Mark incision lines then prep skin

  • Mark areas with at-risk structures such as ulnar nerve (@ medial epicondyle of humerus) and common peroneal nerve (@ neck of fibula)

Technique

  • Make incisions in longitudinal axis with scalpel or cutting cautery, using coagulation cautery for hemostasis along the way

  • Perform in stepwise fashion, reassessing the body part along the way (one incision, recheck, etc)

  • Ideally incision should extend b/w 2 unburnt areas and go down to (but not including) muscle fascia

  • Should go proximal to distal

  • Dress in alginate dressing 

  • Where to make the incision depending on location:

    • Finger: midaxial line 

    • Upper limb: medial/ulnar incision should be anterior to medial epicondyle (avoid ulnar nerve)

    • Lower limb:

      • Medial incision should be posterior to medial malleolus (avoid great saphenous vein or saphenous nerve)

      • Mid lateral incision should curve around fibular neck (avoid common peroneal nerve)

    • Chest: breastplate incision - along anterior axillary line in both sides, connected by 2 transverse incisions in upper chest and upper abdomen


Happy cutting! And don’t forget to consult your local burn specialist prior to this procedure.

Reference

https://www.ncbi.nlm.nih.gov/books/NBK482120/


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