Overview of Escharotomy

When someone gets a burn that goes all the way around a limb, like an arm or a leg, their skin hardens into a tough, leather-like shell, a condition known as “eschar”. In the first two days after a burn, a lot of fluid can build up beneath the skin, which is a result of both the body’s natural response to the burn and the fluid given by doctors to help treat it. But because the “eschar” doesn’t stretch, all this fluid buildup can increase the pressure inside the limb. This increased pressure can cut off blood supply to the tissue, which can cause damage, infection, or stiffening.

The same issue can happen with burns on the chest and belly. A big, deep burn can stop these areas from expanding properly, meaning it might be harder for the person to breathe or for their heart to pump blood around their body properly.

The best way to prevent these problems is with an early operation called an escharotomy. During an escharotomy, a surgeon makes cuts through the burnt skin to release the hard shell and reduce the pressure. This can help restore blood flow to the part of the body affected and make it easier for the person to breathe. An escharotomy is different from other surgical procedures such as fasciotomies, which cut deeper into the body, because it only involves incisions in the skin layer.

However, knowing when an escharotomy is needed can be difficult, as there’s no definitive test to tell when the pressure has become too high. Most often, doctors have to make an educated guess in order to prevent complications from happening. In the medical world, the escharotomy is now considered a part of a broader list of surgeries designed to release pressure build-up in the body after an injury.

Anatomy and Physiology of Escharotomy

The skin is made of two layers: the outer layer called the epidermis and the inner layer, the dermis. Under these layers, we find fat, then a thin layer of tissue before we reach deeper parts like muscles. The thickness of these layers can change depending on where they are on the body, how old a person is, and whether they’re male or female.

When the skin gets burnt, the high heat can damage the proteins that make up our cells. As a result, cells can die. Depending on the depth and severity of the burn, different layers of the skin can be affected.

Superficial burns are minor burns that only involve the outer layer of the skin (the epidermis). These burns usually result in pain and redness, and the affected area will turn white when pressure is applied. This kind of burn hurts when touched because the affected skin is still sensitive to touch.

Partial-thickness burns are more severe and involve both the outer layer (epidermis) and the inner layer of the skin (dermis). These burns might cause the skin to turn pink or a cherry red color and create a blister. Just like superficial burns, these burns also hurt and the skin turns white when pressure is applied. They’re also sensitive to touch.

Full-thickness burns are the most severe and involve all layers of the skin, as well as the fat underneath the skin. This type of burn causes the skin to form a dry, leathery scab called an eschar. These burns might look dry and firm, and the area might feel waxy when touched. However, unlike the other types of burns, full-thickness burns are not painful, do not show a change in color when pressure is applied, and are not sensitive to touch.

Burns that fully wrap around a limb can act like a tight band, hindering blood flow to the area below the burn and causing tissue to die due to lack of oxygen. Burns on the chest or stomach can limit normal breathing movements because the scab that forms is inflexible and doesn’t allow for the normal expansion and contraction of the chest and stomach during breathing.

Why do People Need Escharotomy

Escharotomies are procedures often carried out when treating severe burns. These are typically performed based on the clinician’s judgment of the patient’s state, and how they are responding to care up to that point. This procedure is usually needed when a burn is so severe that it goes around (circumferential) an entire body part, such as an arm or leg, and becomes threatening to blood flow or breathing. Sometimes, it may also be needed for partial thickness burns.

Six key signs to look into include pain, paleness (pallor), odd sensations like tingling or numbness (paresthesia), physical weakness (paresis), irregular temperature (usually, the burned area will feel cooler than the rest of the body), and absence of pulse. Other signs that might show up include oxygen levels lower than 95%, weakened or missing signals, detected by a device called a Doppler, and a high pressure within the muscles (more than 30mmHg).

Burns that fully cover the chest or stomach can hinder full breath and circulatory capacities, leading to difficulties such as breathing problems. The procedure is usually carried out within the first 48 hours after the burn occurs. This timing results from both the initial burn injury and any swelling of tissues due to the body’s response to injury.

For burns on limbs, an escharotomy is carried out if simply elevating the limb does not better blood flow. As for burns on the chest wall, it becomes necessary if these burns affect breathing functions. This can occur even if the burns do not wrap around the entire chest. On the abdomen, the intervention is needed if the burn limits breathing due to a stiffening effect on the diaphragm, particularly in infants under one year old due to their belly-centric breathing pattern.

When a Person Should Avoid Escharotomy

There are only a few situations when a procedure called escharotomy, which is done to relieve pressure caused by severely burned skin, should not be done. This is mainly because not performing it can lead to serious risks, including the loss of a limb or even life. Escharotomy is not needed for minor burns that can heal on their own without the need for surgery. Also, if the burn is not affecting breathing or blood circulation, then this procedure might not be necessary.

Equipment used for Escharotomy

Here is what you might see if you are in the treatment room, these are the tools that will be used for the process:

  • A marking pen
  • Local anesthetic, which is a medicine to numb a specific area of your body; sedation may also be used if needed to help you relax
  • Sterile preparations, like chlorhexidine or non-alcoholic povidone-iodine which are solutions that used to clean your skin before an operation
  • Sterile drapes, which are used to cover you and ensure a clean work area
  • Scalpel, a small, sharp knife used in surgeries: it may or may not be used along with a device called cutting diathermy, which uses heat to cut or remove body tissues
  • Diathermy cauterization device is used to stop bleeding. It works by applying heat to seal off blood vessels
  • Alginate dressing, this is a special type of medical bandage that absorbs fluid and encourages healing.

The good news is, this process does not require too many medical instruments and can be conveniently done right at your bedside. In most cases, you won’t even require a general anesthetic, which means you’ll stay awake but won’t feel any pain or discomfort. Though if necessary, a sedative can be given to help you relax. With a local anesthetic, they will numb the skin in the area where the escharotomy (a surgical treatment used most often to treat severe burns) will be performed. The doctor will use a scalpel or a cutting diathermy to make the incision, and to manage and stop any bleeding, a diathermy cauterization device will be used.

Who is needed to perform Escharotomy?

In an ideal scenario, a special procedure called an escharotomy should be handled by a particular type of doctor who is either a specialist in skin and cosmetic surgery (plastic surgeon) or in treating burns. Sometimes, this procedure can also be done by a doctor who specializes in handling medical emergencies. But before they can perform an escharotomy, these doctors should have a conversation with an expert in treating burns to get the right advice and make sure they are taking the best approach.

Preparing for Escharotomy

The patient should lie flat on their back during the procedure. Both their arms should be facing palm upward, and their legs should be in a relaxed, natural position. Before the procedure starts, the doctor will mark the area where they plan to make the incut. They will also prepare and cover the area to keep it clean and germ-free during the procedure.

The doctor will take special care with certain parts of the body that could be at risk. For instance, they’ll be extra careful around the “ulnar nerve” that is near the inside part of the elbow, and the “common peroneal nerve”, which is near the knee. Protecting these areas is important because they’re located deep within the body and could be harmed during the procedure.

How is Escharotomy performed

An escharotomy is a procedure aimed at treating burns. Following a serious burn, a tight, hard layer of dead skin, known as an eschar, can form. This can cut off blood flow to healthy tissue and can be harmful if not treated. The procedure involves making careful incisions to alleviate pressure and restore blood flow. Although escharotomy is mostly performed on limbs, it can also be done on the chest and neck.

The literature suggests that the incision should be made along the middle line on either side of the limb – either on the outer (lateral) or inner (medial) side. The incision can be performed using a scalpel or a hot instrument, with the latter being used to control bleeding. Ideally, the incision should be made between two areas of unburnt skin and should stop just short of the muscle layer. Cautious care should be taken not to cause injury to deep structures, especially nerves, and not to cross any of the natural skin folds.

The process should be performed gradually, with frequent reassessments of the limb condition after each incision. In some cases, further incisions may be necessary if there is no improvement. Once sufficient pressure is relieved, the incisions can be dressed with a special type of dressing called alginate dressings.

In the case of the upper limb, there are specific guidelines regarding where to make the incision to avoid injuring important structures like nerves. Similarly, for the lower limb and chest, the guidance focuses on avoiding injury to nerves, blood vessels, and veins.

After the procedure, it’s very important to continue to monitor the patient’s condition and regularly check blood flow. Depending on how the patient responds, it might be necessary to extend the incisions or perform an additional procedure, known as a fasciotomy. Similarly, chest and abdominal procedures require careful monitoring of breathing, circulation, and possibly bladder pressure. In some cases, patients may develop an increase in abdominal pressure, which may need to be relieved.

Possible Complications of Escharotomy

Just like with any medical procedure, an escharotomy (a type of surgery to relieve pressure after a severe burn) can have complications related to the surgery itself or the anesthesia used. After an escharotomy, it’s important to closely watch the wound, especially during the first 72 hours, to look for signs that the pressure was not fully relieved. This can lead to issues like poor blood flow in the arms or legs and difficulty breathing in people with chest or stomach burns.

There may also be other issues including bleeding (which can usually be controlled by a procedure called cauterization that stops the flow of blood), infection, and damage to structures nearby the incision, especially specific nerves that lie close to the surface where the cuts are typically made.

Further complications could come up if the escharotomy is not performed properly or is delayed. These may include tissue death due to lack of blood supply, serious risks to nerves and blood vessels that could lead to the need for amputation, difficulty in breathing if the burn is on the chest, and abdominal compartment syndrome (a potentially life-threatening condition in which pressure builds up in the abdomen) if the burn is on the stomach area.

Moreover, there could be complications that effect the entire body such as myoglobinuria (a condition where a protein called myoglobin, which is released when muscle tissue is damaged, gets into the urine), kidney problems, metabolic acidosis (a buildup of acid in the body because the kidneys aren’t working properly), and hyperkalemia (dangerously high levels of potassium in the blood).

In the future, the wounds from the escharotomy may need more surgery, like a skin graft (when skin is moved from one part of the body to another). The surgery might also cause functional problems (like being unable to move a joint as well) and cosmetic issues (like raised scars).

What Else Should I Know About Escharotomy?

When someone gets a full-thickness burn, it significantly affects how the skin works. The skin is supposed to regulate body temperature, help with sweating, stay stretchy, detect touch and sensations, and prevent infections. A full-thickness burn can disrupt these functions.

If the burn covers a full circle around a part of the body, like an arm or the torso (this is called a ‘circumferential burn’), it can cause serious issues. Because skin elasticity is affected, the burned skin can become rigid and act like a tight band around your body part. This could disrupt the flow of blood to the areas beyond the burn. In extreme cases, such a constriction may affect breathing or even become a deadly condition.

However, these scary conditions can often be prevented with quick and proper medical care. This includes something called burn resuscitation, which deals with restoring body systems back to normal and reducing damage from the burn. One technique doctors may use is called escharotomy, where they make a cut through the burned skin to relieve the pressure and restore blood flow and breathing. It’s really important to get help immediately if you or someone else has a serious burn.

Frequently asked questions

1. What is the purpose of an escharotomy and why is it necessary for my burn? 2. How will you determine if I need an escharotomy for my burn? 3. What are the potential risks and complications associated with an escharotomy? 4. What is the expected outcome of the escharotomy procedure? 5. Will I need any additional surgeries or treatments after the escharotomy?

Escharotomy is a surgical procedure that involves making incisions in the skin to relieve pressure and restore blood flow in severe burns. It can help prevent tissue death and improve healing. Escharotomy may be necessary if a burn fully wraps around a limb and hinders blood flow or if it affects the chest or stomach and limits normal breathing movements.

You would need escharotomy if you have severely burned skin that is causing pressure and potentially compromising blood circulation or breathing. Escharotomy is performed to relieve this pressure and prevent serious risks such as limb loss or death.

Escharotomy should not be done for minor burns that can heal on their own without surgery, or if the burn is not affecting breathing or blood circulation. Not getting this procedure can lead to serious risks, including the loss of a limb or even life.

To prepare for an escharotomy, the patient should lie flat on their back with their arms facing palm upward and their legs in a relaxed position. The doctor will mark the area where the incision will be made and will prepare and cover the area to keep it clean during the procedure. It is important for the patient to follow any instructions given by the doctor or medical team prior to the escharotomy.

The complications of Escharotomy include poor blood flow in the arms or legs, difficulty breathing in people with chest or stomach burns, bleeding, infection, damage to nearby structures and nerves, tissue death due to lack of blood supply, risks to nerves and blood vessels that could lead to amputation, difficulty breathing if the burn is on the chest, abdominal compartment syndrome, myoglobinuria, kidney problems, metabolic acidosis, hyperkalemia, the need for additional surgery, functional problems, and cosmetic issues.

Symptoms that require Escharotomy include pain, paleness (pallor), odd sensations like tingling or numbness (paresthesia), physical weakness (paresis), irregular temperature, absence of pulse, oxygen levels lower than 95%, weakened or missing signals detected by a Doppler, and high pressure within the muscles (more than 30mmHg).

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