An escharotomy is a surgical procedure performed to relieve pressure caused by severe burns. It involves making incisions through the tough, non-elastic tissue that forms over deep burns. This intervention is often life-saving, as it prevents serious complications by allowing underlying tissues to expand and receive adequate blood flow.
Understanding Eschar and Its Dangers
When a person sustains a deep burn, particularly a full-thickness or third-degree burn, the damaged skin forms a leathery, stiff tissue called eschar. This eschar is inelastic. As the body initiates an inflammatory response, fluid accumulates under the burn, causing swelling. This swelling, combined with the unyielding nature of the eschar, creates a tourniquet-like effect, increasing pressure on underlying structures.
This increased pressure poses several dangers. In limbs, it can compress blood vessels, leading to a reduction or cessation of blood flow, a condition known as ischemia. Prolonged ischemia can result in compartment syndrome, where pressure within muscle compartments compromises circulation and nerve function, potentially causing tissue death or limb loss. On the torso, especially if the burn is circumferential, the eschar can restrict chest wall movement, making breathing difficult and leading to respiratory distress. Similarly, deep burns on the neck can obstruct the airway.
When Escharotomy Becomes Necessary
The need for an escharotomy is determined by several signs and symptoms. In affected limbs, indications include diminished or absent pulses, detected by palpation or Doppler ultrasound. Other signs are increasing pain or numbness, impaired capillary refill (where the skin does not quickly regain its color after pressure), and coolness or pallor of the extremity. A compartment pressure exceeding 30 mmHg also indicates the need for intervention.
For burns on the chest or neck, progressive respiratory distress, such as shallow breathing, increased respiratory rate, or reduced air entry into the lungs, signals the necessity of the procedure. These observations are continuously monitored, as the decision for an escharotomy is urgent to prevent irreversible damage. Early intervention, ideally within 6 to 8 hours of injury, improves patient outcomes.
The Escharotomy Procedure
The escharotomy procedure involves making incisions through the constricting eschar. These cuts extend through the eschar down to the subcutaneous fat layer. The incisions are usually longitudinal, running along the length of the affected limb or torso, and may extend about one centimeter into healthy skin at the burn’s edges to ensure complete pressure release. Multiple incisions might be necessary depending on the burn’s location and extent.
The procedure is performed using a scalpel or electrocautery. While local anesthesia may be used for surrounding healthy tissue, the burned area itself is relatively insensitive to pain due to destroyed nerve endings. This means the procedure is not cutting into living, healthy tissue but rather the inelastic, non-viable eschar. After the incisions, the release of pressure is visible as the wound edges gape open.
Care Following Escharotomy
After an escharotomy, the incisions are typically left open, not closed with stitches, to allow for continued decompression and prevent pressure from building up again. These open wounds require meticulous management to prevent infection. This involves regular dressing changes, wound cleaning, and topical antimicrobial agents. Continuous monitoring ensures improved circulation and, in chest burns, unrestricted breathing.
Pain from surrounding healthy tissues requires management. The open wounds created by an escharotomy are a temporary measure. Once the initial swelling subsides and the wound bed is healthy, these areas will typically require further surgical treatment, such as skin grafting, to promote healing and provide permanent skin coverage. This subsequent procedure is a key step in the patient’s long-term recovery.