2. Escharotomy Techniques

3. Definition
• Eschar: A thick, coagulated crust, slough which
develops following a burn injury or chemical or
physical cauterization of skin.
• In full thickness circumferential burns, coagulated
collagen acts as a tourniquet in leading to vascular
compromise of the affected body parts.
• Escharotomy: incision of eschar for decompressing
the constrictive effects caused by deep
circumferential burns.

4. Pathophysiology
• A circumferential deep or full thickness burn is inelastic and
on an extremity will not stretch.
• Fluid resuscitation --> burn wound oedema & swelling of
tissue beneath the inelastic burnt tissue.
• Increased tissue pressure may result in progressive
obstruction of venous & lymphatic drainage, capillary
perfusion, and ultimately, arterial flow.
• Prolonged tissue ischaemia --> irreversible muscle & nerve
damage
• Systemic complications: myoglobinuria, hyperkalaemia,
metabolic acidosis, renal failure.
• Site-specific implications: extremities, chest, abdomen.

5. Indications
• Clinical examination
• Direct tissue pressure measurement

6. Indications - Clinical Examination
• Circumferential deep dermal or full thickness burns
• 5 Ps: pain, pallor, paraesthesia, paresis, pulselessness.
• Could be difficult in severely burned patients
• Important features:
– Pain worse on passive stretch of affected muscle
– Pain disproportionate with that expected from the injury
– Extremity usually swollen, taut, and tender to palpation
– Sensory deficit - earliest & the most sensitive finding
– Motor deficit - late
– Pulselesness - irreversible tissue damage

7. Indications - Tissue pressure
• Direct tissue pressure monitoring - objective means
for measuring compartment pressures
• Invaluable adjunctive diagnostic technique for
assessing the indications for and also the adequacy
of escharotomy or fasciotomy.
• Several methods available: open needle, wick
catheter, and slit catheter techniques.

9. Indications - Tissue pressure
• Normal intramuscular pressure: 0 - 10mmHg
• Starling equilibrium: capillary perfusion diminishes or ceases
at pressures that exceed 30mmHg
• Therefore some recommended surgical decompression for
compartment pressures > 30mmHg
• However, compartment syndromes were not observed to
occur until the pressure exceeds 45mmHg
• Critical threshold pressure for surgical decompression:
– Tissue pressure > 30-40mmHg;
– Tissue pressure within 30mmHg of diastolic pressure.

10. Incisions
• Medial and lateral aspects of the extremities to avoid
damage to major neurovascular structures.
• Incisions must traverse the depth of the eschar to
viable tissue as well as the length of the eschar to
unburned skin.
• Must cross affected major joint areas where the
attachment of skin to deep fascia is more secure
than elsewhere

29. Complications
• Bleeding
• Damage to neurovascular structures
• Infection
• Inadequate or delayed decompression

32. Summary
• Role of escharotomy in deep circumferential burns is crucial for relief of
peripheral ischaemia or respiratory embarrassment.
• Indications should be based on both careful clinical assessment and
appropriate tissue pressure monitoring.
• Proper escharotomy incisions should cover the full depth and length of
the eschar over the circumferential burned area.
• Timely escharotomy results in prompt improvement of distal ischaemia or
respiratory compromise, with subsequent preservation of tissue and
optimal functional results.
• Further surgical decompression (eg. fasciotomy, laparotomy) may be
required if escharotomy is not sufficient to relieve tissue ischaemia.