Escharotomy

• Indications
  • Circumferential full-thickness (third-degree) burns of the chest, abdomen, or limbs
  • Evidence of vascular compromise in limbs: pulselessness, delayed capillary refill, paraesthesia, pain out of proportion, or pallor
  • Impaired ventilation due to chest wall restriction in circumferential torso burns
• Preparation
  • Ensure analgesia and/or sedation (general anaesthesia if possible)
  • Aseptic technique, with chlorhexidine or iodine skin prep
  • Use monopolar diathermy or scalpel
  • Mark incision lines
• Limb escharotomy (usually performed medially and laterally to avoid neurovascular bundles)
  • Upper limb:
    • Incisions along medial and lateral aspects
      • Medial: from axilla to wrist, along ulnar side
      • Lateral: from deltoid insertion to radial wrist
    • Avoid injury to ulnar nerve (medially) and cephalic vein (laterally)
  • Lower limb:
    • Incisions along medial and lateral aspects from groin to ankle
      • Medial: avoid saphenous vein
      • Lateral: stay anterior to fibula to avoid peroneal nerve
  • Cut through the eschar only, until underlying fat bulges or the wound visibly separates
  • Fasciotomy may be required if compartment syndrome is suspected or perfusion does not improve
• Chest escharotomy
  • Vertical or curvilinear incisions along mid-axillary lines, connecting horizontal incisions at the clavicle and costal margin
  • Relieves restriction on chest expansion
• Post-procedure care
  • Monitor for improved perfusion or ventilation
  • Cover incisions with moist dressings or paraffin gauze
  • Continue analgesia and begin wound care
  • Plan for eventual debridement and grafting if required