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Summary

Escharotomy is an emergency surgery performed in individuals with circumferential, full-thickness burns. In such people, all three layers of the skin become dry and inelastic. Also, the fluids in the subcutaneous fat layer shift to the nearby tissue space and increase tissue pressure that affects the blood circulation and respiratory mechanism of the body. During escharotomy, the surgeon makes cuts on the burnt skin to release the pressure and restore normal blood flow and respiration, thus preventing limb- and life-threatening conditions. Extensive wound care and nutritional support in the hospital is needed after the procedure. You may also need additional surgeries such as fasciotomy, skin grafting, or cosmetic surgeries to improve skin function and appearance and replace damaged skin with healthy skin. The length of your hospital stay may extend from several weeks to months, depending on the seriousness of the condition. 

  1. What is escharotomy?
  2. Why is escharotomy recommended?
  3. Who can and cannot get escharotomy?
  4. What preparations are needed before escharotomy?
  5. How is escharotomy done?
  6. How to care for yourself after escharotomy?
  7. What are the possible complications/risks of escharotomy?
  8. When to follow up with your doctor after an escharotomy?

Escharotomy is an emergency surgery for the treatment of compromised muscle movement or blood circulation caused by full-thickness, circumferential burns.

Human skin has three layers, namely epidermis (outer layer), dermis (middle layer), and subcutaneous fat layer (deepest layer). Dermis contains nerves, blood vessels, sweat glands, and hair follicles, whereas the subcutaneous fat layer includes fat cells that act as shock absorbers. Both these layers contain a special protein called collagen that gives strength and flexibility to the skin. Exposure to heat and other similar injuries causes the collagen break down and cell death.

Superficial burns damage the epidermis and cause pain and skin redness. Partial-thickness burns damage both the epidermis and dermis and result in similar symptoms along with the formation of blisters. Full-thickness burns affect all three layers of the skin and cause the skin to lose it elasticity and become leathery, dry and inflexible. Such tissue is called eschar.

As a result of burns, fluids in the subcutaneous fat layer shift to the space between cells and increase the pressure within the tissue. Since the overlying burned tissue becomes dry and inelastic, when eschar forms on an area, it leads to an increase in pressure on blood vessels in the area, restricting circulation. When eschar forms on the chest and abdomen, it affects respiration. 

Escharotomy relieves this pressure and restores normal blood circulation and respiratory mechanism of the body. If the surgery is not performed, it could result in severe repercussions such as nerve injury, muscle necrosis, metabolic acidosis, and hyperkalaemia.

This surgery is recommended in individuals with full-thickness and circumferential deep dermal burns in the limbs or chest.

Limb burns are associated with the following symptoms:

  • Signs of loss of circulation such as coolness and pale appearance
  • Numbness
  • Low levels of oxygen in the blood

Deep burns in the chest lead to:

  • Restricted movement of the abdomen or chest
  • Shallow breathing
  • Abnormal rate of respiration

Since full-thickness burns can result in life-threatening consequences, there are very few instances in which the surgeon will not perform this procedure. Escharotomy is not done in people with superficial burns that can be treated without surgery and when the respiratory mechanism and blood circulation are not compromised.

Escharotomy is an emergency surgical procedure during the hospital stay for deep burns to restore blood circulation and facilitate proper respiration.

If you have suffered such a burn and are being treated for it in a hospital, your doctor will check the blood flow to your heart and blood vessels and monitor your fluids and electrolytes closely. If compromised blood circulation and respiratory mechanism are suspected, you will be moved to the operating room for escharotomy. An antibiotic will be given to you before the surgery to prevent infection.

You will be asked to lie on your back with your arms perpendicular to your body and palms facing upwards.

The surgery usually involves the following:

  • A person from the surgical team will clean the area to be operated using a povidone-iodine solution and cover you with sterile surgical drape to prevent contact with unsterile surfaces, surroundings, and equipment.
  • During the surgery, the part of your body, in which the cut (incision) is to be made, will be undressed and re-dressed in a sequential manner to prevent your body’s exposure to the environment. In addition, this is essential to maintain normal body temperature. Heat lamps or blankets may also be used to prevent low body temperature.
  • The surgeon will use a surgical marker to draw lines for the incisions. The markings are made such that the lines go beyond the burnt skin at least 1 cm into the normal skin. In case of burns on limbs, the markings are usually made on either side of the affected leg and hand; whereas a rectangle marking or shield-like marking is made on the affected torso.
  • Local anaesthesia (a numbing medicine) will be administered into the healthy skin in which the cuts have to be made.
  • The surgeon will use a surgical blade or electrocautery (a process in which electric current is passed through a metal wire to generate heat) to make incisions on the markings. The incisions are made deep into the skin until the subcutaneous fat layer is seen.
  • The surgeon will run a finger along the cut to check for any remaining restrictive areas that can compromise blood circulation.
  • He/she will check your breathing and blood circulation to ensure that adequate incisions have been made to release tissue pressure.
  • If there is excessive bleeding from any incision, the surgeon will close the area either with sterilised thread or a deep-heating method.
  • Finally, the incision will be covered with a dressing.

After the surgery, you will undergo rigorous wound care and nutritional support until your wounds are closed. This will help control infection and promote wound healing.

If the burns are on your limbs, they will be kept in an elevated position. Your surgeon will monitor your condition regularly to assess the need for additional surgeries like fasciotomy (surgery to relieve tissue pressure and swelling) and skin grafting (surgery to replace damaged skin by healthy skin). During the hospital stay, you will undergo a comprehensive evaluation to address mobility, skin assessment, respiration, scar management, etc. You may also require reconstructive or plastic surgery to improve skin function and appearance. 

The period of hospital stay after an escharotomy depends on the severity of burns and the requirement of intensive acute care intervention. Hence, the duration of hospital stay usually extends from several weeks to months in individuals with deep burns. You will be discharged from the hospital when you have minimal scarring, maximal range of motion and can function independently.

Once you return home after the surgery, you will need to practise exercises and follow self-care instructions provided by the surgeon. You may also need to visit a speech therapist, psychiatrist, or occupational therapists to restore the quality of life.

When to see the doctor?

Contact your doctor immediately if you observe any signs of infection such as swelling, redness, discharge, and warmth around the burnt or operated area.

The complications associated with the surgery include:

  • Infection in the open incisions
  • Excessive blood loss
  • Bacterial infection in the underlying tissue
  • Injury to the underlying tissue
  • Accidental cutting of the connective tissue that holds internal organs of the body
  • Abnormal scarring
  • Septic shock

You will need to visit the surgeon for a follow-up within 10 days of discharge from the hospital for postoperative evaluation.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.

References

  1. Zhang L, Hughes PG. Escharotomy. [Updated 2020 Jul 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan
  2. Stanford Healthcare [Internet]. University of Stanford. California. US; Anatomy of the Skin
  3. Ellison EC, Zollinger Jr RM. Zollinger’s atlas of surgical operations. 10th ed. McGraw-Hill Education; 2016. Chapter 146, escharotomy; p. 556.
  4. Oda J, Ueyama M, Yamashita K, et al. Effects of escharotomy as abdominal decompression on cardiopulmonary function and visceral perfusion in abdominal compartment syndrome with burn patients. J Trauma. 2005 Aug. 59(2):369-74.
  5. Gravante G, Delogu D, Sconocchia G. "Systemic apoptotic response" after thermal burns. Apoptosis. 2007 Feb. 12(2):259-70. PMID: 17191115.
  6. Schulze SM, Weeks D, Choo J, et al. Amputation Following Hand Escharotomy in Patients with Burn Injury. Eplasty. 2016. 16:e13. PMID: 26977219.
  7. Agency for Clinical Innovation [Internet]. New South Wales Government. Australia; Escharotomy for burn patients
  8. World Health Organisation [Internet]. Geneva. Switzerland; WHO Surgical Site Infection Prevention Guidelines
  9. Brigham Health [Internet]. Brigham and Women's Hospital. Massachusetts. US; Standard of Care: Inpatient Physical Therapy Management of Patients with Burns
  10. Beth Israel Lahey Health: Winchester Hospital [Internet]. Winchester. Maryland. US; Fasciotomy
  11. Nova Scotia Health Authority [Internet]. Canada; Discharge instructions after you leave the burn unit
  12. Chelsea and Westminster Hospital [Internet]. NHS Foundation Trust. National Health Service. UK; Escharotomy
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