Escharotomy should be performed when circumferential or near circumferential eschar of the extremities compromises the underlying tissues or the circulation distal to it. Escharotomy should be performed when eschar on the trunk or neck compromises aeration and breathing.
Considerations in formulating Recommendation 1
No randomized controlled studies have addressed the treatment of extremities or truncal compartment syndromes. Several retrospective or prospective cohort studies have described the frequency of performing escharotomies/fasciotomies in at-risk burn patients [94–99]. Although the exact timing of escharotomy was not mentioned in most of the literature, escharotomy is generally indicated after initiation of ﬂuid therapy. In their series, Piccolo et al. mentioned having performed immediate escharotomies in 11% of cases . Nevertheless, these authors did not address the exact timing of the procedure (before or after resuscitation), time lapse since injury, and cause of injury. Moreover, the article did not specify whether the 11% of cases pertained to the total number of patients treated or the total number of escharotomies performed. The authors noted that escharotomies were performed in 11% of patients at risk (i.e., with deep circumferential extremity burns) immediately after admission. In contrast, another 17% of patients at risk required escharotomy after several hours of resuscitation with intravenous ﬂuids.
Indirect support for the association between initiation of ﬂuid therapy and development of compartment syndrome derives from literature on abdominal compartment syndrome (ACS) in patients without burns. Tuggle et al. conducted a systematic review of ACS and noted that intraabdominal hypertension was observed only after ﬂuid infusion was begun . Furthermore, these authors observed a correlation between ACS incidence and the volume of the ﬂuid infused. Because of this, patients with large burns (>40% total body surface area, TBSA) are more likely to need escharotomies.
In a systematic review based on fourteen articles and conducted by the Evidence-based Guidelines Group of the American Burn Association, the authors stated clearly that ‘‘escharotomies rarely are required immediately postburn’’ . It is worth noting that all the reviewed references dated from 1958 to 1988.
Conversely, escharotomy is rarely, if ever, required after ﬂuid resuscitation has been completed (i.e., more than 72 h after the burn). The decision to perform escharotomy should be based on clinical ﬁndings supported by appropriate invasive or non-invasive monitoring. The ﬁrst step is to ensure that there are no systemic causes of distal hypo perfusion, such as hypoxia, decreased cardiac output, hypovolemia, or peripheral arterial constriction .
Normal capillary ﬁlling is a clinical ﬁnding with high speciﬁcity and negative predictive value. That is, when capillary ﬁlling in the nail beds of the extremity at risk shows a brisk return of perfusion within 3 s, there is little likelihood that the burn is restricting blood ﬂow. However, the converse is not true: sluggish capillary ﬁlling is not always diagnostic of hypoperfusion secondary to restrictive circumferential burns because there are other systemic causes of hypoperfusion in injured patients. Similarly, Doppler ﬂow signals in the radial, ulnar, posterior tibial, or dorsalis pedis arteries do not normally exclude performing an escharotomy, although progressive weakness or absence of signals is an indication for escharotomy. The presence of distal pulses does not rule out the presence of early compartment syndrome, however, because the amount of pressure required to reduce arteriolar or capillary ﬁlling is much less than that required to cease blood ﬂow in the larger arteries.
Pulse oximetry, measuring oxyhemoglobin saturation with simple and inexpensive equipment, may be more helpful for decisions regarding escharotomy because values above 95% suggest adequate distal perfusion, whereas values below 90% indicate a need for escharotomy. Values between 90% and 95% are concerning but require further investigation. (The admonition for the use of pulse oximetry is that carbon monoxide poisoning will falsely elevate the oxyhemoglobin level, leading to a false negative ﬁnding.) Direct intra-compartmental pressure measurement, if available, helps in the decision, although it is not available in hospitals in resource-limited settings (RLS). Compartmental pressure below 25 mmHg is associated with adequate tissue perfusion, while pressure above 40 mmHg is an absolute indication for escharotomy. Pressures between 25 and 40 mmHg require clinical correlation with other ﬁndings [94–100].
Note: As not all patients at risk (i.e., those with deep circumferential extremity burns) require immediate escharotomy, treatment plans should address minimizing subsequent development of intramuscular hypertension. Such plans should include reducing the volume of ﬂuid resuscitation to what is just required to ensure adequate organ perfusion (typically a urine output of 0.3–0.5 mL/kg/h in adults and 1 mL/kg/h in children) and elevating the affected extremities to reduce edema. Elevation should not be so excessive as to cause traction on the limb; elevate to just above the heart level [94,100].
Balance of beneﬁts and harms
The golden rule of escharotomy is to perform the procedure whenever there is doubt as to its need. The risk of complications from unnecessary escharotomy is much lower than the risk of not performing escharotomy when it is indicated. Clinicians commonly make three mistakes related to escharotomies: (1) failing to perform escharotomies when needed, or performing escharotomies with inadequate length and/or depth, resulting in persistent hypoperfusion and subsequent tissue necrosis; (2) extending the incision too deep and thereby damaging underlying functional structures such as nerves or tendons; and (3) performing unnecessary escharotomy in burn skin that eventually heals without grafting, leading to aesthetic impairment due to the unsightly scar caused by the escharotomy incision.
Avoidance of the third mistake is highly desirable, avoidance of the second is essential; but occurrence of the ﬁrst mistake is disastrous. In cases of doubt, and to avoid unnecessary escharotomies, ﬁrst elevate the limbs until there may be spontaneous resolution of edema by gravity. If the compromise persists, the escharotomy should be performed [94,100].
Values and preferences
An escharotomy is of great value; it might save a life and/or a limb. Preference should always be given to performing the procedure when in doubt, particularly in full thickness circumferential burns. Clearly, it is better to save a patient’s life though he/she may live with a severe scar than to lose the limb or the patient in an attempt to avoid scarring.
Particularly in RLS, escharotomy is almost always a bedside procedure. As this procedure is performed without anesthesia, and needs no special equipment or even instruments (maybe cautery in some cases), its cost is negligible. In infants and children, heavy sedation, even anesthesia in occasional cases, might be indicated. Even in these cases, however, the procedure will not take long, making it an inexpensive and cost-effective treatment.
Abdominal escharotomy should be performed when circumferential or near-circumferential eschar is associated with evidence of intra-abdominal hypertension (IAH) or signs of abdominal compartment syndrome (ACS).
Considerations in formulating Recommendation 2
Further research is likely to have an important impact on practice decisions, and thus may change the reference points currently used to guide whether to perform surgical release of pressure [94–99,102]. Abdominal compartment syndrome is a serious condition associated with many types of injuries. Burn is a relatively uncommon cause of ACS, and burn patients may develop ACS in the absence of deep burns of the abdominal wall, for example, as a sequela to massive blunt trauma, overresuscitation, or septic shock . Therefore, the presence of abdominal eschar does not indicate ACS and conversely, the absence of abdominal eschar does not exclude the presence of ACS. This phenomenon suggests that external restriction and compression by burn eschar plays a minimal role in the development of ACS. Moreover, many burn patients with ACS die despite receiving abdominal escharotomies, which raises questions about the efﬁcacy of escharotomy in treating ACS. The most commonly used method to diagnose ACS is determination of intravesical pressure (IVP) through a catheter inserted in the urinary bladder. The normal range of IVP is below 5 mmHg but it is accepted at up to 12 mmHg in cases of trauma. Values above 25 mmHg necessitate intervention, while values between 12 and 25 mmHg indicate the need for close observation for evaluation [101,102].
Important note: ACS is suspected when there is an unexplained reduction in minute ventilation, oliguria, or both. It should also be suspected not only in patients with major burns but particularly in those who have received an amount of ﬂuid resuscitation well beyond that predicted based on weight and burn size. Ultrasound might help in the diagnosis. In cases where intra-abdominal pressure (IAP), assessed through intra-compartmental needle measurement, is above 25 mmHg, decompression is necessitated via abdominocentesis, laparoscopy or laparotomy [94,100–102].
Balance of beneﬁts and harms
The golden rule of escharotomy applies to the abdominal eschar: perform the procedure whenever there is any evidence of increased IAP or ACS. In comparison to procedures involving limbs and the neck, abdominal escharotomy is much safer as no vital structures or vessels pass superﬁcially in the whole trunk. However, a real danger presents itself in cases of very deep eschar where the incision has a far reach, such as to the peritoneum, and when the procedure is performed by an inexperienced person.
Values and preferences
Performing escharotomy is always preferred when there are signs of increased IAP. In very deep wounds, an experienced person (general or burn surgeon) should perform the escharotomy. When experienced surgeons are unavailable, escharotomy should be performed with the most experienced person present. Extreme caution should be taken to identify and avoid going too deep into the muscles. When in doubt, stop at the level reached and allot time to inspect the IAP signs and changes. Meanwhile, try to arrange for a burn surgeon or general surgeon to ensure a safe outcome.
Instruments and equipment for measuring IAP or IVP might not be available in most centers. In addition, ultrasound might not be conclusive. Therefore, an easy and applicable way to detect ACS is to insert a venous femoral catheter. In addition to allowing ﬂuid transfusion, catheterization allows monitoring of IAP. Any slowing or interruption of ﬂuid ﬂow in the catheter highly suggests the rise of IAP.
Escharotomy should be performed in the longitudinal axes of the affected part near the neurovascular bundles. The extent of the incision in the eschar should range from normal skin to normal skin. If this is not possible, the range should extend from joint above to joint below. The depth of the incision is limited by reaching healthy tissue at the base.
Considerations in formulating Recommendation 3
No clinical trials or well-designed studies have attempted to investigate the quality of evidence surrounding this recommendation; the strength of recommendation is based solely on several case series and expert opinion as well as accepted clinical practice [94–99].
The objective of escharotomy is to break the tourniquet effect of any eschar that affects blood ﬂow. Therefore, it would be most effective to place the release incisions near but not exactly over the affected neurovascular bundles and along their course so that they will be released without being exposed or injured. Limb incisions are therefore longitudinal and in the mid-axial lines (medial and lateral), except in hands and feet where incisions are on the dorsum. Trunk escharotomies might need to be enhanced by transverse incisions in the upper parts of the thorax and abdomen to allow expansion in all axes of both compartments.
To ensure full release, it is recommended that the incision be deep enough to reach a healthy tissue at the base . To ensure decompression, whenever possible, the incision should extend 1 cm in healthy skin or in a superﬁcial burn, proximal and distal to the eschar. If not possible, it is preferable to surpass the incision to the next proximal joint . Veins should be avoided and spared; if impossible, ligation is preferred to ensure bleeding control. No superiority of either scalpel or electrocautery in incision has been noted in the literature . Nevertheless, most guidelines recommend electrocautery because of the ease of controlling bleeding [97,98]. As with all surgical procedures, attention should be given to adequate analgesia and sedation, as well as maintenance of a clean, if not sterile, operative ﬁeld.
Important note: Monitoring for clinical and investigational indications of escharotomy should be continued hourly for at least 72 h after burn. The most frequent complication is bleeding (subdermal plexus and superﬁcial veins) while the most serious is incomplete release [94,95, 99,100].
Injury to deep structures is rare because in most cases the incision should extend to the level of upper subcutaneous fat only and should reach, but not include, the superﬁcial fascia. Evidence of success is the bulging of the subcutaneous fat from the base of the incision, absence of ﬁbrous bands in the incision, profuse exudation of edema ﬂuid from the wound, and disappearance of the clinical and investigational indications [97–100].
Balance of beneﬁts and harms
The golden rule of escharotomy is to perform the procedure whenever there is doubt as to its need. The complications of unnecessary escharotomy are far fewer than those of not performing escharotomy when it is indicated. Sticking to the rules minimizes complications. Mid-axial incisions in limbs, and dorsum of hands and feet, make the escharotomy—even very deep ones—a safe procedure.
Values and preferences
Escharotomy is always preferred when its need is in doubt; it is a simple, safe and effective procedure. Nevertheless, improvisation is strictly prohibited; inexperienced staff should never attempt to perform escharotomy as the complications in this case might outweigh the beneﬁt. Therefore, to ensure safe outcomes, the preference is to train all emergency workers to perform escharotomy. In these days of heightened means and timing of communication there is always an opportunity to discuss the decision prior to performing the procedure.
Apart from patients needing general anesthesia (infants and young children), escharotomy requires no special equipment or even instruments. Even in cases involving infants and young children, however, the procedure will not take long, making it inexpensive and cost-effective.
Apart from high-voltage electrical injuries, fasciotomy is rarely indicated as a primary procedure in burns. Fasciotomy is more commonly performed once the diagnosis of compartment syndrome has been conﬁrmed, particularly in cases of very deep burns, whatever their etiologies.
Considerations in formulating Recommendation 4
No randomized controlled studies of the treatment of extremity human compartment syndromes have been conducted, though several retrospective studies describe the frequency with which escharotomies and fasciotomies have been performed in burn patients at risk [94–96,100].
Fasciotomy is indicated for compartment syndrome. Diagnosis and investigations are similar to those that precede escharotomy. Fasciotomy might be indicated when the clinical and investigational picture of compression persists following escharotomy. Compression of deep structures, such as nerves, may lead to paresthesia. Pain on passive muscle stretching is an indication for fasciotomy. Complications of fasciotomy are the same as those of escharotomy but occur much more commonly, particularly the injury to neurovascular bundles and deeper structures .
Balance of beneﬁts and harms
Fasciotomy, in contrast to escharotomy, is a more technically challenging procedure. It requires general anesthesia. As the cuts reach deeper levels of tissue, the risk of all complications, and particularly that of injury to neurovascular bundles, is much higher. This procedure should be performed by experienced burn or general surgeons only. The other real danger is the massive exposure and desiccation of deeper structures, particularly that of the muscles. Therefore, the decision to perform fasciotomy should be arrived at cautiously and preferably supported by investigational hard evidence.
Values and preferences
The decision to perform fasciotomy should always be made cautiously, particularly in cases of non-electric burns. Escharotomy alone should be performed initially; when this fails to achieve intended outcomes, fasciotomy should be done without much hesitation if the compression picture persists. In cases of electric burn, particularly when muscular necrosis is evident, fasciotomy has another advantage: direct inspection of muscles for early excision of the necrotic tissue, thus preventing acute renal failure, infection, and further limb loss . Therefore, there is no role for closed fasciotomies in burns; all the fasciotomies should be open and open fasciotomy should be seriously considered in cases of high voltage electric burns.
Compared to escharotomy, fasciotomy is more expensive, as it requires general anesthesia, and postoperative care of the wound is more demanding. Moreover, reconstruction after fasciotomy is far more demanding. Nevertheless, though the total cost of fasciotomy is much higher than that of escharotomy, it is far and away the better option cost-wise given the risks and costs of a lost limb.
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