Escharotomy and Burn Care

Used to decompress accumulated edema under tight, unyielding eschar following full-thickness burn (classic and modern classifications of burns are given in TABLE 74.1)

Circumferential extremity burn with evidence of neurovascular compromise:

Cyanosis

Deep tissue pain

Progressive paresthesia

Decreased or absent pulses

Elevated compartment pressure

Decreased arterial flow on Doppler ultrasonography

Pulse oximetry <95% of affected extremity (without systemic hypoxia)

Thoracic burn with evidence of respiratory compromise due to eschar

Circumferential neck burn

Abdominal burn with evidence of increased intra-abdominal pressure (usually estimated by bladder pressure)

Circumferential penile burn

CONTRAINDICATIONS

No evidence of tissue hypoperfusion on physical examination

Normal findings on arterial Doppler ultrasonography

Adequate respiration despite eschar

No evidence of increased intra-abdominal pressure

RISK/CONSENT ISSUES

Often difficult to obtain consent from major burn victims; escharotomy is a life-saving procedure and should be performed even if informed consent from the patient cannot be obtained

Procedure can cause pain (local and systemic analgesia will be provided)

Risk of bleeding (minimized with proper technique)

Whenever the skin is broken, there is potential for introducing infection (sterile technique will be utilized)

TABLE 74.1.

BURN DEPTH CLASSIFICATION

LANDMARKS

Escharotomy sites are depicted in FIGURE 74.1.

TECHNIQUE

General Basic Steps

Airway, breathing, and circulation (ABC)

Consider early intubation

Fluid resuscitation

Analgesia

Tetanus prophylaxis

Wound care

Escharotomy

FIGURE 74.1 Escharotomy sites. (From Haro LH, Miller S, Decker WW. Burns. In: Wolfson AB, ed. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:315, with permission.)

BURN MANAGEMENT

First ensure ABC and administer supplemental oxygen

Strongly consider endotracheal intubation if:

Burns to the face and neck are present

Soot in and around the mouth and nose

Hoarseness, stridor, wheezing, or development of acute coughing

Carbonaceous sputum

Give intravenous fluids for resuscitation (for moderate to major burns)

Use Parkland formula: Ringer lactate 4 mL × weight (kg) × % of total body surface area (TBSA) burned (excluding superficial burns)

Give ½ of total volume over the first 8 hours from time of burn injury

Give second ½ of total volume over the following 16 hours

Titrate to maintain blood pressure and urine output of at least 1 mL/kg/hour

Continue maintenance fluids in addition

Place urinary catheter to monitor adequate resuscitation (FIGURE 74.2)

Provide pain management with frequent pain assessment

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS) with or without opioids for superficial burns

Opioids are necessary for partial-to-full thickness burns

Administer tetanus prophylaxis

Wound care, if not delaying transfer to burn unit:

Use sterile technique

Clean with mild soap and tap water

Debride sloughed or necrotic skin; avoid extensive debridement

Remove ruptured blisters

Intact blister management is controversial; it is recommended to unroof cloudy blisters or those where rupture is imminent (e.g., over joints)

FIGURE 74.2 Methods to evaluate percentage of body surface area burned. A: Rule of Nines. B: Lund and Browder chart. (From Haro LH, Miller S, Decker WW. Burns. In: Wolfson AB, ed. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:1103, with permission.)

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