このエピソードについて
Escharotomy involves incision of inelastic burned tissue (eschar) that can impair perfusion of the extremities, as well as restrict chest wall movement and ventilation.
Indications:
- Limb hypoperfusion
- Ventilation restriction
Limb Hypoperfusion
Can occur with circumferential AND non-circumferential burns.
Note: There is insufficient evidence to support any specific standard, or test, to aid the clinician in deciding whether an escharotomy is needed.
Traditionally, the decision to perform an escharotomy has been based on the following clinical signs:
- Reduced skin temperature
- Decreased capillary refill time
- Reduced/absent pulses (very late sign)
- Complaints of deep aching pain, progressive loss of sensation or paraesthesia (these parameters are difficult to assess in a severely burned, sedated or mechanically ventilated patient)
Clinical assessment of skin temperature and pulses may be unreliable indicators of perfusion due to peripheral vasoconstriction and local oedema. Conversely, peripheral pulses may be palpable despite severe underlying muscle ischaemia.
Most escharotomy decisions are, however, made on the clinical assessment of the burn size, site and depth, and indeed in burns centres, may be performed prophylactically.
The following objective signs can also be used to aid decision making*:
- Doppler - Repeated measurements may be necessary and progressive reduction in flow likely warrants action. Absence of arterial flow is an immediate indication for escharotomy.
- Compartmental pressures - Pressure of > 40mmHg warrants immediate escharotomy. Consider for pressures between 25-40mmHg with other clinical features of hypoperfusion.
- Pulse oximetry - Saturation of < 95% in circumferentially burned extremity warrants consideration of escharotomy (in the absence of systemic hypoxia).
*Please note: there is little evidence to support the use and interpretation of the following aids and, in fact, they are rarely performed by burns specialists. However, on occasion they may help the inexperienced provider in decision making:
Ventilation Restriction
- Can present with circumferential AND non-circumferential burns
- Chest or upper abdominal burns can impair respiration
The following objective signs can also be used to aid decision making:
- Persistent arterial hypercapnia in mechanically ventilated patients
- Elevated peak inspiratory pressures
- Paediatric patients: predominant diaphragmatic breathing, so even non-circumferential burns, limited to anterior chest and abdomen, may require escharotomy
Contraindications:
No specific contraindications. If the chance of survival is deemed to be very low the decision to proceed should be carefully considered.
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Further reading »Kupas DF, Miller DD. Out-of-Hospital Chest Escharotomy: A Case Series and Procedure Review. Prehospital Emergency Care (2010) 14:3, 349-354
Victorian Burns Guideline - Early Management - Escharotomy
Victorian Burns Guideline - Initial Management & Secondary survey
Wheeless Online Textbook of Orthopaedics - Escharotomy
New Zealand National Burn Service, Escharotomy Guideline (2014).
Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. J Burn Care Res 2009;30:759-68.
Saffle J. Practice guidelines for burn care. Boston, MA: American Burn Association; 2001.
Moylan JA Jr, Inge WW Jr, Pruitt BA Jr. Circulatory changes following circumferential extremity burns evaluated by the ultrasonic flowmeter: an analysis of 60 thermally injured limbs. J Trauma 1971;11:763-70.
Bardakjian VB, Kenney JG, Edgerton ML, et al. Pulse oximetry for vascular monitoring in burned upper extremities. J Burn Care Rehabil. 1988;9:63.
