Escharotomy is used to decompress constrictive effects caused by deep circumferential burns. The eschar forms a tight inelastic layer over swollen tissue, obstructing blood flow. Indications for escharotomy include circumferential deep dermal or full thickness burns with signs of vascular compromise like pain, pallor, numbness. Tissue pressure monitoring can objectively measure compartment pressures, with surgical decompression recommended over 30-40 mmHg. Proper escharotomy incisions must fully traverse the eschar depth and length to relieve constriction while avoiding major structures. Timely escharotomy preserves tissue and function by relieving ischemia.

2. Escharotomy Techniques

3. Definition
• Eschar: A thick, coagulated crust, slough which
develops following a burn injury or chemical or
physical cauterization of skin.
• In full thickness circumferential burns, coagulated
collagen acts as a tourniquet in leading to vascular
compromise of the affected body parts.
• Escharotomy: incision of eschar for decompressing
the constrictive effects caused by deep
circumferential burns.

4. Pathophysiology
• A circumferential deep or full thickness burn is inelastic and
on an extremity will not stretch.
• Fluid resuscitation --> burn wound oedema & swelling of
tissue beneath the inelastic burnt tissue.
• Increased tissue pressure may result in progressive
obstruction of venous & lymphatic drainage, capillary
perfusion, and ultimately, arterial flow.
• Prolonged tissue ischaemia --> irreversible muscle & nerve
damage
• Systemic complications: myoglobinuria, hyperkalaemia,
metabolic acidosis, renal failure.
• Site-specific implications: extremities, chest, abdomen.

5. Indications
• Clinical examination
• Direct tissue pressure measurement

6. Indications - Clinical Examination
• Circumferential deep dermal or full thickness burns
• 5 Ps: pain, pallor, paraesthesia, paresis, pulselessness.
• Could be difficult in severely burned patients
• Important features:
– Pain worse on passive stretch of affected muscle
– Pain disproportionate with that expected from the injury
– Extremity usually swollen, taut, and tender to palpation
– Sensory deficit - earliest & the most sensitive finding
– Motor deficit - late
– Pulselesness - irreversible tissue damage

7. Indications - Tissue pressure
• Direct tissue pressure monitoring - objective means
for measuring compartment pressures
• Invaluable adjunctive diagnostic technique for
assessing the indications for and also the adequacy
of escharotomy or fasciotomy.
• Several methods available: open needle, wick
catheter, and slit catheter techniques.

9. Indications - Tissue pressure
• Normal intramuscular pressure: 0 - 10mmHg
• Starling equilibrium: capillary perfusion diminishes or ceases
at pressures that exceed 30mmHg
• Therefore some recommended surgical decompression for
compartment pressures > 30mmHg
• However, compartment syndromes were not observed to
occur until the pressure exceeds 45mmHg
• Critical threshold pressure for surgical decompression:
– Tissue pressure > 30-40mmHg;
– Tissue pressure within 30mmHg of diastolic pressure.

10. Incisions
• Medial and lateral aspects of the extremities to avoid
damage to major neurovascular structures.
• Incisions must traverse the depth of the eschar to
viable tissue as well as the length of the eschar to
unburned skin.
• Must cross affected major joint areas where the
attachment of skin to deep fascia is more secure
than elsewhere

29. Complications
• Bleeding
• Damage to neurovascular structures
• Infection
• Inadequate or delayed decompression

32. Summary
• Role of escharotomy in deep circumferential burns is crucial for relief of
peripheral ischaemia or respiratory embarrassment.
• Indications should be based on both careful clinical assessment and
appropriate tissue pressure monitoring.
• Proper escharotomy incisions should cover the full depth and length of
the eschar over the circumferential burned area.
• Timely escharotomy results in prompt improvement of distal ischaemia or
respiratory compromise, with subsequent preservation of tissue and
optimal functional results.
• Further surgical decompression (eg. fasciotomy, laparotomy) may be
required if escharotomy is not sufficient to relieve tissue ischaemia.