TY - JOUR
AU - PhD, Jayme Adriano Farina, Jr, MD,
AB - Abstract Escharotomy incisions must be made in the inelastic skin eschar that is typical of circumferential third-degree burns. Later, the necrotic tissue must be debrided and substituted with a skin graft. Many reports on this topic have revealed that concepts and techniques vary widely. This study aims to present a critical review of the literature about escharotomy in burns and to highlight a different strategy to perform escharotomy in patients with burned extremities. We conducted a critical review in Pubmed/MEDLINE using the keywords “escharotomy” and “burns.” In the present study, we included 22 articles published from 1955 to 2015 (60 years) that contain the aforementioned keywords. With respect to the extremities, most of the publications recommend that medial and lateral longitudinal incisions be performed and that care must be taken to avoid deep structures, particularly nerves. Moreover, the publications mention that escharotomy might result in thick, hypertrophic, retracting, and painful scars. We advocate that incisions performed only on the lateral and medial borders of the extremities are usually unnecessary, and that they contribute to the creation of misconceptions about burns. In addition, these incisions can somehow trigger complications that can be avoided by using the concept of escharotomy in multiple directions, as highlighted in this review. Physicians frequently indicate escharatomy to treat patients with full-thickness burns. Although Wallace1 did not employ the term “escharotomy,” he was one of the first surgeons to conduct incisions through the tissue of burned limbs, to improve circulation.2 Third-degree circumferential burns of the limbs lead to a noncompliant eschar. After severe burns, fluids move from intravascular to extravascular and extracellular spaces, increasing the pressure within the compartments in the limbs. If this pressure is not released, it may lead to ischemia and necrosis of the tissues in extremities.3 Therefore, incisions should be made only in the inelastic skin eschar typical of circumferential third-degree burns. Later, the necrotic tissue should be debrided and substituted with a skin graft. The medical literature on escharatomy is abundant. However, analysis of the countless publications shows that the concepts and techniques vary widely and are sometimes contradictory. To date, evidence to support a standardized method to perform escharotomy has been insufficient.3 This study aims to present a critical review of the literature and to highlight a different strategy to perform escharotomy in patients with burned extremities. METHODS We conducted a critical review of articles and we searched on a Pubmed/Medline database by using the keywords “escharotomy” and “burns.” This study included articles that combined the aforementioned keywords and were published from 1955 to 2015 (60 years). All the articles could be accessed in Pubmed and were written in the English language. We selected all the articles related to escharotomy in burns, with emphasis on patients with burns in extremities. Some case reports and other studies that were not related to the main issue were excluded. A total of 22 articles were selected. We classified the studies according to the level of evidence (from I to V) based on the Evidence Rating Scale for Therapeutic Studies of the American Society of Plastic Surgeons4 (Table 1). Some studies, like animal studies, review articles, letters, and editorials, are not ratable in this scale. Table 1. Evidence rating scale for therapeutic studies from American Society of Plastic Surgeons4 View Large Table 1. Evidence rating scale for therapeutic studies from American Society of Plastic Surgeons4 View Large We analyzed the selected articles for information regarding the indication of escharotomy, the right time to perform it, the professional that should perform it, the anesthesia protocol, and the technique and complications related to escharotomy. RESULTS Concerning the level of evidence, we classified nine of the 22 articles we included in this review as level 5 (case reports and expert opinions), six as level 4 (case study), and one as level 3 (retrospective cohort). We were unable to classify six articles (four review articles and two experimental studies; Table 2). Table 2. Articles included in this review, their design, and level of evidence View Large Table 2. Articles included in this review, their design, and level of evidence View Large In the following sections, we report on the central concepts of escharotomy described in the literature, highlighting and discussing the variations we noted in the conclusions of the articles we analyzed. For better readability, we grouped the issues into topics. Indication for Escharotomy Almost all the articles reviewed herein indicate escharotomy for full-thickness (third degree) circumferential burns in the extremities and thorax. In the particular case of the limbs, the full-thickness necrotic tissue prevents the limb skin from dilating in the presence of edema, thereby compressing blood vessels (disturbing the bloodstream in the extremities) and nerves. In the thorax, third-degree burn in which the necrotic tissue is inelastic prevents the thoracic cage from expanding satisfactorily, which may culminate in respiratory insufficiency. The presence of inextensible circumferential full-thickness burned skin requires that escharotomy be performed in the limbs. If the burn occurs around the whole circumference of the extremity, formation of edema impairs the bloodstream, a situation that reaches its most critical point within 24 to 48 hours. Besides, full-thickness skin burn demands debridement and grafting, which are procedures that routinely take place within a few days after burning. Hence, escharotomy may be necessary even before debridement is performed, to normalize circulation in the burned limb.18 According to Orgill & Piccolo,3 decreased or absent oximetry or Doppler probe signal, increased compartment pressures, and sudden onset of neurological symptoms are common reasons to perform an escharotomy. These authors believe that the long-term decision on whether to perform an escharotomy is ultimately based on experience and overall clinical judgment. Compartment pressures above 40 mm Hg will lead to tissue ischemia, and pressure levels between 25 and 40 mm Hg may damage the tissue. The authors propose that physicians perform immediate escharotomy when oxygen saturations from pulse oximetry fall below 95%. However, these authors pinpoint that escharotomy can cause significant morbidity, and that it generally is not necessary to wait for several hours into the burn resuscitation. After the procedure, continued monitoring is essential to evaluate whether escharatomy needs to be extended. Some authors also favor escharotomy to treat full-thickness burn of the abdominal wall and to improve the parameters of intraabdominal hypertension.5,17 Burned patients submitted to abdominal escharatomy present significantly positive changes, like decrease in the bladder, gastric, and central venous pressure, increased systolic blood pressure, and improved respiratory function with correction of acidosis. Early escharotomy helps to prevent intraabdominal hypertension. If intraabdominal hypertension already exists, early escharatomy avoids the life-threatening abdominal compartmental syndrome, a natural evolution of untreated intraabdominal hypertension. Kupas & Miller6 also mention that escharotomy can help to manage cervical burns. Other authors indicate escharotomy for partial-deep thickness burn,13,15 but this procedure may be unnecessary in this type of burn. According to Salisbury,24 although second-degree partial-thickness burn can be waxy white, it is smooth, which contrasts with the third-degree burn, in which the burned tissue is tough, tight, and inelastic. The rates of escharotomy in burned patients vary widely in the literature and range from 9.2 to 54%.19 Handschin et al9 have shown that escharotomy rates are significantly higher in high-tension electrical injuries (47%) as compared with thermal burns (21%). Almost all authors indicate escharotomy to treat third-degree burns, but Piccolo et al13 also employ this technique to manage partial-deep thickness burn. Curiously, these same authors recommend that the incisions should penetrate all the eschar until they reach the subcutaneous tissue. If the incisions cross all the eschar and enter the subcutaneous tissue, we can infer that the necrotic tissue involves all the dermis, that is, it is a third- and not a second-degree burn. This conceptualization is necessary—it leads to the concept that physicians should always perform escharotomy on full-thickness necrotic tissue that will later be debrided and substituted with a skin graft. However, we should not be so dogmatic about the indication of escharotomy. There certainly are cases of mixed-pattern burns (particularly in patients that require significant volume resuscitations) where the necessary releases might well extend to the deeper tissues even though the burn is not formally considered a full-thickness burn. In these patients, releases might well have to include potentially salvageable tissues and, in these situations, we recommend that planning incisional approaches should strongly be considered to minimize subsequent deformity. According to Kamolz et al,7 prompt escharatomy should be performed in the event of a near circumferential or circumferential deeper burn and increasing edema. Missing pulse of the radial or ulnar artery under adequate resuscitation is probably a sign of progressive ischemia and requires immediate escharotomy. Regardless of burn depth, escharotomy will be inevitable when fingers are affected, the dorsum of the hand looks pale white, the nail bed is deregulated, and loss of sensibility can be noted. In an emergency, escharotomy can be performed at bedside under sterile conditions, but it is desirable that the procedure be conducted in the operating room. Nowadays, escharotomy is classified as part of a larger group of decompressive therapies like fasciotomy, decompressive laparotomy, and nerve release.3 In this context, Burd et al14 propose changing the concepts concerning the treatment of the compartmental syndrome. The idea is to extend the technical procedure of escharotomy to a continual process of decompression that involves longer monitoring and frequent re-evaluation. Besides, decompression includes loosening the bandage and correcting the position of the limbs (at the heart level). These authors stress that decompression has to be considered for all body compartments where a rise in compartmental pressure can impair vital function. These compartments include the intracranial and extracranial head and neck, the thorax, the abdomen, and the limbs. Geary & Pape16 have reported the case of a young man with circumferential full-thickness burns in the lower limbs. Because parallel investigations delayed the patient's transfer, physicians performed escharotomy on both lower limbs. Fasciotomy was later necessary due to muscle herniation. According to these authors, the literature has no objective criteria concerning the conduction of escharotomy associated with fasciotomy. The authors point out that this decision should be based on clinical judgment, and the surgeon must have a high index of suspicion to perform the necessary procedures early. Balakrishnan et al8 highlight that third-degree burns of hands or wrists are important causes of acute carpal tunnel syndrome—the eschar forms a tight band that constricts the circulation distally. Clinically, this condition can be diagnosed by increasing pain with paresthesia of median nerve distribution. Escharotomy is indicated to relieve the symptoms in this case. Balakrishnan et al8 described seven patients that were submitted to escharatomy under general anesthesia. Six weeks later, the patients presented improved electromyographic exams. Escharotomy was performed in association with tourniquet without exsanguination of the extremity. The wound was left open and closed after the edema had decreased. The Right Time to Perform Escharotomy In the case of the thorax and extremities, escharotomy must be accomplished when the respiratory function and the innervation/circulation are compromised, respectively. Regarding the limbs, the decision to perform escharotomy relies on clinical findings including paresthesia, pulse evaluation, cyanosis in the distal nonburned skin, slow capillary filling and deep tissue pain, oximetry, ultrasound imaging, and intramuscular pressure.13,21,22 For the thorax, lack of thoracic cage expansion and signs of respiratory insufficiency are reasons for escharotomy. As for the abdomen, indication for this procedure depends on the intraabdominal pressure.17 Escharotomy has usually been performed in the phase of larger edema (up to 48 hours after the burn incident). Sometimes, escharotomy should be conducted in the thorax soon after the burn. Indeed, Kupas & Miller6 have reported two cases of urgent thorax escharotomy performed in the helicopter that transported the victims to the hospital. In the particular case of the thorax, other authors also consider that escharotomy might be necessary during prehospital assistance.25 Saffle et al22 believe that escharotomy should be performed when two consecutive measurements of intramuscular pressure exceed 30 mm Hg (if recorded), or when arterial pulses in the brachial, radial, or palmar arch cannot be detected with a Doppler ultrasound device. These authors advocate that physicians should perform escharotomy along the medial part of the supinated arm, and that incision should be made through the burned tissue, down to the fascial layer. If pressures exceed 30 mm Hg again, or if pulses are not restored, lateral escharotomy should be performed. After escharotomy, the intramuscular pressure should decrease significantly, rapidly reducing edema and causing the patient to regain motion and strength. Prophylactic indication of escharotomy might be a good option in limb burns, but accomplishing escharotomy soon after the burn event is rarely necessary. Bardakjian et al21 propose that escharotomy should be conducted when oxygen saturation is below 95%. In these cases, escharotomy promotes prompt return of the oxygen levels to normal values. Pulse oximetry detects changes in oxygen levels early, before the clinical signs appear. According to Lawton & Dheansa,11 escharotomy should be included among the initial procedures advocated in the advanced trauma life support (ATLS) protocol. Early and correct escharotomy is an important measure to avoid complications, such as amputation, sepsis, and respiratory damage, in the case of full-thickness and circumferential eschars in the trunk. Experimental data suggest that nerves and muscles are irreversibly damaged within 12 to 24 hours and 4 to 12 hours, respectively. Therefore, these authors recommend that time on scene be considered in burned patients because they need to be transferred to a burn center as fast as possible. In this context, decompression procedures are essential to save the limbs. Handschin et al9 discuss the different literature opinions about the right time to indicate escharotomy: immediately or selectively. These authors recommend escharotomy only in patients with massive tissue edema associated with other signals and symptoms, like pain, peripheral nerve dysfunction, circumferential burns, flexion contracture, venous congestion, and suspicion of distal ischemia in the burn injury. Who Should Perform Escharotomy? Saffle et al22 considers that only experienced professionals should accomplish escharotomy. In fact, this author advocates that the patient be transferred to a specialized unit when the need for escharotomy arises. Kupas & Miller,6 who belong to a team of physicians that deliver prehospital care, have performed thorax escharotomy on two extremely urgent occasions, inside the helicopter used to transport the victims. Even though this procedure is not part of protocols of extra-hospital care, Kupas & Miller6 mention that it should be because it is a simple, safe, and life-saving intervention. Given that escharotomy is a simple and important technique, it deserves to be assimilated by emergency doctors, no matter whether they are clinicians or surgeons. In the absence of physicians, even trained paramedics can conduct escharotomy, especially in the thorax, where it might be more urgent. Although most of the other authors highlight that severe injuries can happen during escharotomy, they do not specify who should accomplish this procedure. We consider escharotomy a simple technique. Apparently, the more the physician knows about the technique and experiences it, the better. Ideally, escharotomy should always be performed in specialized units. However, in urgent cases (which is not the rule for limbs), we believe that physicians that do not have much experience with the technique could perform it. Learning acquired by the urgency care team in emergency rooms will suffice, as long as training relies on fundamental concepts and does not include unnecessary details that might overwhelm the nonspecialist. Anesthesia Lawton & Dheansa11 propose that escharotomy should be performed in an operating theater under general anesthesia (regardless of the insensate nature of the eschar). The procedure should be sterile and involve an aseptic technique; it should also be able to ensure hemostasis and to replace blood loss.11 In contrast, other authors affirm that incision only involves dead tissue, which dismisses the need for anesthesia.13 Technique About the position of the incisions, most articles propose that the eschar be divided by performing incisions down the long axis of the limb in mid-medial or mid-lateral lines through the dermis or down to deep fascia, taking care to avoid damaging any important underlying structures, particularly nerves. Piccolo et al13 advocate performing longitudinal incision in the radial border. If necessary, these authors also recommend conducting longitudinal incision in the ulnar border of the upper limbs. The reason for this recommendation is that excision of the necrotic tissue in the limb will not always be followed by skin grafting, so a linear scar in other positions could become hypertrophic and painful. The same rationale justifies incision along the medial line of the second and fourth metacarpals, to release the compartments and reduce the risk of retraction of the interdigital space due to the presence of a scar that may become hypertrophic. For the fingers, these authors favor incisions in the lateral borders of the first, fourth, and fifth fingers and in the medial borders of the second and third fingers. Kamolz et al7 propose that an incision on the arm and hand is best performed by electrocautery, which reduces bleeding. Most publications recommend medial and lateral longitudinal incisions.3,22,26 Pegg20 advocates against performing incisions through the flexing joint folds.20 Nevertheless, Burd et al14 recommend that escharotomy incisions must be initially made at the same sites where fasciotomy will be later performed, if necessary. In other words, these authors believe that escharotomy should not be performed in the medial or lateral borders of the limbs. According to these authors, some technical principles should be followed: damage to cutaneous nerves should be avoided, longitudinal veins should be preserved where possible, straight line incisions across joints should be prevented, and direct decompression of major nerves and vessels must be performed as indicated. As for depth, most authors state that incisions must involve the necrotic skin only, and they recommend extra care in the case of deep structures, particularly nerves.3,6,13,20,26 According to Pegg,20 incisions must only be deep enough to allow the borders to move apart. Lawton & Dheansa11 propose extending the concept of escharotomy to a more embracing process of decompression. Durrant et al12 suggest that escharotomy should involve incision through the burn to the fat beneath, allowing the burn eschar to move independently and relieving the underlying tissue pressure. The fascia remains unbreached in this case, which differentiates between this procedure and fasciotomy. Nevertheless, these authors propose that fasciotomy may also be necessary in patients with significant burns and massive tissue edema. Ali et al10 have described an interesting experimental model to train professionals for escharotomy. The model consists of a prosthetic arm covered with foam, involved by a compressive leather outer layer. The foam mimics the subcutaneous fat tissue, whereas the leather simulates skin with a third-degree burn. Incision of the outer layer elicits expansion of the underlying, compressed foam, which in turn dismisses the need for an incision. In 1973, Richards & Feller23 introduced the concept of grid escharotomy to debride burns. Grid escharotomy allows earlier removal of necrotic tissue layers and reduces the risk of wound infections because it drains infectious material in the subeschar space more effectively. According to the authors, grid escharotomy needs to be differentiated from the traditional escharotomy performed in burned patients to reduce the compartmental pressure. In other words, the authors do not consider grid escharatomy a decompressive procedure. Grid escharatomy is well tolerated and can be performed without anesthesia, because full-thickness burns are insensitive. The grid is constructed by measuring 1-inch squares. As for the depth, it only runs through the eschar and does not involve the granulation tissue. Escharotomy incisions should only be performed on full-thickness burned skin that will soon (within a few days) be surgically removed and replaced with a skin graft. Therefore, we believe that professionals performing escharotomy do not have to worry that the incision sites will result in scars; that is, in our opinion, professionals do not need to avoid flexing or extending folds or positioning incisions in the medial or lateral longitudinal lines of the limbs. Hence, we agree with the concept of grid escharotomy previously mentioned by Richards & Feller,23 but with reservations. We believe that escharotomy on multiple directions (not necessarily in the “grid” format) is an efficient decompressive procedure. Its depth is the same depth performed for other lines of escharotomy. Based on our experience, we recommend that incision lines be performed at any direction (according to the patient's requirement), that sites potentially leading to nerve injuries be avoided, and that a sufficient number of incision lines be made to release the compartment satisfactorily (Figure 1). Figure 1. View largeDownload slide Escharotomy incisions on multiple directions, not only on medial and lateral longitudinal borders of the upper limb (above and below). Figure 1. View largeDownload slide Escharotomy incisions on multiple directions, not only on medial and lateral longitudinal borders of the upper limb (above and below). To prevent surgery-related shortcomings, enzymatic escharotomy has been used to release the pressure of circumferential constricting third-degree or deep second-degree eschars of the limbs. Eschar-specific removal agents enriched with bromelain have been indicated to dissolve burn wound eschar. Bromelain agents are already being used in Europe and are currently undergoing controlled trials in the United States. Enzymes dismiss the need for knife incision and anesthesia and avoid the complications of surgical escharotomy. According to Rosenberg et al,27 compared with excisional debridement, enzymatic debridement with an agent enriched with bromelain reduces the need for extended surgery and provides comparable long-term results in patients with deep burns.28 Complications Most authors advocate extra care to avoid nerve, vessel, or tendon injuries during escharotomy.15,22 Nevertheless, Young26 argues that escharotomy does not harm these structures because the incisions only reach the burned skin, which, as a third-degree lesion, will have to be debrided and consequently replaced with skin graft. Saffle et al22 stresses that escharotomy along the medial and lateral aspects of the extremity avoids major neurovascular structures. In most cases, incisions must include all the full-thickness of the burned skin, but nothing further, so as to minimize the risk of injuring deeper structures. Few regions of the limbs contain relatively superficial vascular-nervous structures. The most notable exception is the ulnar nerve, located on the medial line of the elbow. The usual recommendation is to conduct incision exactly at this site, although authors caution that physicians should take care not to injure the nerve, localized a little deeper to the skin. Incisions in other regions of the limb eliminate the risk of harming this nerve. While some authors believe that significant bleeding may take place, other states exactly the opposite (that is, bleeding is generally negligible).3,15 Bleeding events may be treated with cauterization.20 Another possible complication of escharotomy is soft tissue infection, which can be prevented with the use of topical antibiotics or early excision and autografting of all deep, partial, and full-thickness burns.20–22 Pegg20 avoids flexing folds, but this author does not offer any detailed explanations for this conduct. Piccolo et al13 mentions that escharotomy could result in thick, hypertrophic, retracting, and painful scars. Because escharotomy incisions in the burned skin should include all the burn thickness, and bearing in mind that skin graft will later replace the burned skin, we believe that hypertrophic scars will not emerge at these incision sites (Figure 2). Figure 2. View largeDownload slide Escharotomy must occur on the inelastic skin typical of circumferential third-degree burns (above). After the skin grafting, there is no scar where the escharotomy incisions were made (below). Figure 2. View largeDownload slide Escharotomy must occur on the inelastic skin typical of circumferential third-degree burns (above). After the skin grafting, there is no scar where the escharotomy incisions were made (below). RECOMMENDATIONS AND LIMITATIONS Guidelines for Teaching and Training For education and training purposes, we propose guidelines for indication and performance of escharotomy based on our experience, as follows: In the extremities, incision should be placed in the inelastic skin typical of circumferential third-degree burns (full-thickness burned skin); There are no fixed positions to place the incisions; it is possible to accomplish any number of incisions that will ensure good perfusion in the extremities (Figure 1); Hypertrophic scars usually do not emerge due to the incision of a full-thickness burned site; a skin graft will later replace it (Figure 2); The incisions must go through the skin and reach the subcutaneous tissue; they should be enough to move the borders apart immediately while ensuring that deeper structures remain unaffected. Strengths and Limitations This review comprises several concepts related to escharotomy in burned patients, especially patients with burns in extremities. This review improves understanding of this issue and provides recommendations for better clinical practice. Selection of the 22 studies from the past 60 years was based on their relevance and on the evidence that each article provided to this review. Some literature studies may have been missed because we have included only articles that were available in full and we have excluded research that was not available in the English language in Pubmed. A limitation of this review is that most of the analyzed articles (15 studies of 22) were classified as case reports/expert opinions or case study (level of evidence 5 or 4, respectively). This indicates that the data related to escharotomy in burns were obtained from studies placed on lower levels of the evidence pyramid. Therefore, their results, conclusions, and recommendations should be adopted with criticism and reservation. However, some surgical interventions (like escharotomy) do not lend themselves well to higher-level study designs such as randomized controlled trials because they are ethically unacceptable. Hence, case study, case reports, and review articles help to identify directions that lead to positive outcomes in clinical conditions that are treated surgically or that are associated with high morbidity.29 Finally, we must be careful not to adopt an inflexible approach of only applying pieces of evidence or recommendations of higher strength. In clinical practice, some uncommon pathologies and complex conditions cannot be investigated by using study designs that achieve levels of evidence greater than 3 or 429. CONCLUSION Escharotomy is a relatively simple procedure that improves blood circulation and thoracic expansion in burned patients. Any physician that is familiar with the technique should perform this procedure. There are no particular positions for the incisions in the extremities, but they should not be deeper than the thickness of the burned skin. Incisions only on the lateral and medial borders of the limbs are usually unnecessary, and they contribute to the creation of misconceptions about burns. Besides, they can somehow trigger complications, which can be avoided by using the concept of escharotomy on multiple directions highlighted in this review. REFERENCES 1. Wallace AB Assessment and emergency treatment of burns. Br Med J  1955; 2: 1136– 8. Google Scholar CrossRef Search ADS PubMed  2. Pruitt BA Jr, Dowling JA, Moncrief JA Escharotomy in early burn care. Arch Surg  1968; 96: 502– 7. Google Scholar CrossRef Search ADS PubMed  3. Orgill DP, Piccolo N Escharotomy and decompressive therapies in burns. J Burn Care Res  2009; 30: 759– 68. Google Scholar CrossRef Search ADS PubMed  4. 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Google Scholar CrossRef Search ADS PubMed  Copyright © 2016 by the American Burn Association
TI - Revisiting Escharotomy in Patients With Burns in Extremities
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000476
DA - 2017-07-01
UR - https://www.deepdyve.com/lp/oxford-university-press/revisiting-escharotomy-in-patients-with-burns-in-extremities-UvK8vMioSl
SP - e691
EP - e698
VL - 38
IS - 4
DP - DeepDyve
ER -