Burn Guideline : Escharotomy and fasciotomy in burn care

Burn Guideline : Escharotomy and fasciotomy in burn care

Recommendation 1
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 [100]. 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 [101]. 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’’ [96].  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 [95].
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.

Recommendation 2
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 [102]. 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.

Recommendation 3
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  [98]. 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 [99]. 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 [97]. 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.

Recommendation 4
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 [100].

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 [94].  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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