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.*

Thoracic Escharotomy

INDICATIONS

are the presence of a circumferential eschar with one of the following:

1. 2.

Impending or established vascular compromise of the extremities or digits Impending or established respiratory compromise due to circumferential torso burns[6]

Capillary refilling time, Doppler signals, pulse oximetry, and sensation distal to the burned area should be checked every hour.* Subsequently, any increase in capillary refill time, decrease in Doppler signal, or change in sensation should lead to rechecking the compartment pressures.

 Compartment

Pressure

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

DECISION- MAKING ALGORYTHM

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, the risks and potential complications of performing an escharotomy are to be weighed carefully against the benefits. [9]

ANESTHESIA

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

EQUIPMENT
Sterile

drapes solution

Povidone-iodine

Electrocautery*

Dressing

materials

POSITIONING

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

PROCEDURE & TECHNIQUE

1.

2.

3.

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

4.

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

5.

6.

7.

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

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

COMPLICATIONS

Complications of inadequate decompressionor of not performing an escharotomy when indicated are severe. They include the following:
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, renal failure, 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, which can become desiccated. Incision/injury to the underlying healthy tissue including neurovascular structures, especially in the extremities and digits

Bacteremia: Underlying tissue may be infected, and the manipulation can result in bacteremia and septic shock. If underlying infection is suspected, the escharotomy should be performed under antibiotic coverage. 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. These wounds also contribute to the ongoing insensate fluid losses in a manner similar to the burns wounds.

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.* It is a clinical procedure indicated once the clinical diagnosis of compartment syndrome is made. 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.*

Fascial compartments
y

are unforgiving connective tissue septa and osseous structures. Without sufficient compliance of these structures, 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. A high clinical suspicion for compartment syndrome along with serial examinations without the use of compartment pressure measurements is also used

INDICATIONS

Indications for surgical intervention in acute compartment syndrome in the alert patient are generally based on clinical impression. Four signs and symptoms are commonly referred to as the 4 P's, as follows:
1. 2. 3. 4.

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

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

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

PATHOPHYSIOLOGY

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

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.

General

EQUIPMENT

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

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

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

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