An escharotomy is an urgent surgical procedure involving an incision through nonviable, burned tissue to alleviate pressure in patients with severe burns. This intervention is reserved for individuals who have sustained deep, full-thickness burns that encircle a body part, such as a limb, the chest, or the neck. The procedure cuts through the thick, leathery layer of dead skin, known as the eschar, which forms over the damaged area. A successful escharotomy prevents complications that arise when this rigid tissue constricts the underlying structures.
The Medical Rationale for Escharotomy
Full-thickness burns destroy the skin’s entire layer, including nerve endings and the ability to stretch, resulting in the formation of a stiff, non-elastic eschar. Following a severe burn injury, the body initiates a massive inflammatory response, causing large amounts of fluid to leak from damaged capillaries into the surrounding tissues. This fluid accumulation, or edema, is exacerbated by necessary intravenous fluid resuscitation and causes the underlying muscle and soft tissue to swell significantly.
When the eschar completely encircles an extremity, its inelastic nature prevents the swelling tissue beneath it from expanding outward. This creates a tourniquet-like effect, rapidly increasing the pressure within the confined anatomical space, known as burn-induced compartment syndrome. If the pressure exceeds the capillary filling pressure (30 millimeters of mercury), it collapses the small blood vessels, halting blood flow to the limb and resulting in tissue death. For burns covering the torso, the rigid eschar similarly restricts the chest wall’s movement, severely compromising the patient’s ability to breathe and leading to respiratory failure.
The escharotomy releases this constricting pressure and restores adequate circulation to the affected limb or allows for full expansion of the chest wall. Without immediate decompression, the lack of oxygenated blood flow can lead to muscle necrosis, nerve damage, and potentially the need for amputation. The decision to perform an escharotomy is based on clinical signs of impaired perfusion, such as a diminished or absent pulse signal detected by Doppler ultrasound, or signs of compromised ventilation.
Executing the Procedure
The escharotomy is an urgent procedure performed at the patient’s bedside in the emergency department or intensive care unit, often without general anesthesia. Since the full-thickness burn has destroyed the skin’s nerve endings, the eschar itself is insensitive to pain, though local anesthesia may be used where the incision extends into unburned tissue. The surgeon uses a scalpel or an electrocautery device to make the incisions.
For a limb, the procedure involves creating long, longitudinal cuts along the medial (inner) and lateral (outer) aspects of the extremity. These incisions run the entire length of the constricting eschar, extending slightly into the healthy tissue at both ends to ensure complete release. The depth of the cut is controlled to go through the full thickness of the burned skin, stopping when the underlying subcutaneous fat is exposed. A correctly executed incision results in an immediate separation or gapping of the wound edges, confirming that the pressure has been relieved.
To decompress a circumferential burn of the chest, incisions are made bilaterally along the anterior axillary lines, running from the clavicle down to the costal margin. These vertical incisions are often joined by a horizontal cut across the upper abdomen to form a rectangular release of the torso. The surgical team must avoid damaging underlying vital structures, such as superficial nerves and major blood vessels that run close to the planned incision lines.
Immediate Post-Procedure Care
Following escharotomy, the focus shifts to continuous monitoring of the patient’s circulation and respiratory status. The surgical team observes the wound for signs of bleeding, controlled using electrocautery or pressure, and confirms the return of adequate blood flow to the distal limb. This confirmation involves frequent checks of the pulses, capillary refill time, and the strength of the Doppler signal in the affected extremity.
The wounds created by the escharotomy are not closed immediately; they are left open for ongoing decompression and drainage. The open incisions must be dressed with sterile, antimicrobial dressings, such as gauze impregnated with silver sulfadiazine, to prevent infection in the newly exposed tissue. Due to the large open wound, the patient is at an increased risk of fluid loss and difficulty regulating body temperature, requiring specialized monitoring and environmental control.
The patient’s condition, including limb perfusion and respiratory effort, is reassessed frequently over the following 48 to 72 hours to ensure the initial procedure was sufficient. If signs of constriction persist, the surgeon may need to extend the original incisions or perform a deeper procedure called a fasciotomy. Once the initial swelling subsides and the patient is stabilized, they are prepared for definitive wound closure, typically involving skin grafting.