Escharotomy

Escharotomy is a surgical technique which helps to relieve compression of body areas which are affected by a deep burn. Evaporation of water and thermal coagulation of proteins in the skin makes the collagen fibrils of the dermis shrink. In combination with the onset of post-traumatic collateral and generalized edema of the subcutaneous tissue, first the capillaries, veins, and later also the arteries are compressed, and the affected areas become ischemic and die. The main areas at risk are the neck, eyelids, limbs and chest.

General information
The location and depth of the burn injuries represent important data for the patient's transport to a specialized workplace and further surgical care. The most serious location include the face, neck, hands, perineum, genitals and soles of the feet.

In the case of developing facial edema and deep circular burns around the neck, chest or trunk, breathing problems may occur, therefore the medical emergency service performs endotracheal intubation immediately at the scene of the accident.

Procedure

 * In the case of circular coagulative necrosis on the neck (Fig. 1), which compresses primarily the jugular veins, it is necessary to make incisions in the affected area even before transport (Fig. 2): the incision is made in a saw-tooth fashion from the angle of the mandible through the trigonum caroticum to the medioclavicular line in order to release the subcutaneous tissue and to prevent intracranial venostasis which can lead to intracranial edema, local ischemia and decebration. This escharotomy can be performed under intravenous analgesia and sedation because the full-thickness necrosisis of skin renders the affected area insensitive. Incisions will cancel the pressure of coagulation necrosis and the counterpressure of collateral edema. The developing subcutaneous edema creates a relatively safe space above the blood vessels, so there is no need to worry about their injury. The incision removes the two forces that close the jugular veins and act as a tourniquet. In this situation of pre-hospital care, we cover the releasing incisions with a compress and apply a dry bandage over it. If other loosening cuts are necessary, we perform them only at a specialized workplace.
 * On the upper limbs, the incisions are made from the axilla, along the volar side of the limb, through the ulna. It crosses the canalis carpi and the incision extends 1-2 cm into the palm. If there is insufficient relaxation of the tense tissues, it is advised to make another cut on the dorsal side of the limb as well. The cut is again saw-toothed to achieve maximum release of compression.
 * On the lower limbs, we make a releasing incision along the lateral side of the thigh, around the head of the fibula, along the lateral side of the lower leg, behind the outer ankle to the edge of the instep, and we often connect the incision on the tibial side as well (see diagram 1).
 * Incisions on the chest and trunk (if constricted by rigid coagulative necrosis) can be postponed until admission to a specialized workplace. They are most often performed on both sides of the chest, saw-toothed along the front axillary line. If necessary, additional incisions of solid necrosis are made. (Fig. 3).
 * Relaxing incisions are not usually made on the abdomen.


 * When the face is more superficially affected, the edema is most pronounced in the area of ​​the eyelids, which tend to be tightly closed and cannot be opened. The closure of the eye slits, and therefore the inability to orientate at the scene of the accident, can endanger the patient. He depends on the help of those around him, and if he doesn't get the help he needs, his blindness prevents him from escaping the scene of accident.
 * In the case of deep burns of the face, developing collateral edema under the shrinking coagulative necrosis evertes the tarsi of the upper eyelids, so that the upper edge of the everted tarsi presses on the cornea and may be the cause of decubitus, possibly. ulcus corneae, which can endanger patient's sight. A releasing incision in the orbitopalpebral sulcus (see diagram 2 and figs. 4 – 6) will enable the reposition of the everted tarsus and prevent ophthalmological complications.
 * In the case of a circular deep burn of the penis, it is not possible to retract the foreskin over the glans and properly clean the sulcus and prepare it for the insertion of a urinary catheter. Therefore, it is necessary to make a longitudinal incision on the dorsal side in the shape of a flat S.

In institutional care, strips with antibacterial cream are applied to the incisions. Suitable synthetic covers (COM, etc.) can also be attached.

Deep myonecrosis can occur in the case of high-voltage electrotrauma, rendering a simple incision of the skin and subcutaneous tissue ineffective. Acute collateral edema develops in muscle groups, oppressing microcirculation and causing muscle ischemia in fascial compartments. Therefore, we still need to complete the fasciotomy of the affected muscle groups to relieve them of the increasing pressure (Fig. 7).

Related articles

 * Surgical treatment of burns