Escharotomy Procedure

In very serious burns, the tissue that remains can form an eschar. This eschar no longer resembles skin nor does it have the same elastic properties of native skin or most tissues. An eschar is inelastic, tough, and prevents the normal movement of surrounding structures. An escharotomy is a surgical procedure in which the eschar is removed.

 

There are certain cases in which an escharotomy must be removed urgently or emergently. Consider a third degree burn that has affected a person’s lower leg under its full circumference. As the eschar forms, as with any scar, it shrinks. This shrinking squeezes and constricts the underlying tissue. Since the entire circumference of the leg is affected, the muscles, tendons, and blood vessels under the eschar are compressed. This situation leads to a condition known as compartment syndrome which can ultimately lead to loss of the limb. Therefore, an urgent or emergent escharotomy is needed to remove the eschar and save the limb.

 

 

Another instance in which escharotomy must be performed without delay is for serious burns and eschar formation around the torso. As the eschar shrinks and constricts, it can seriously interfere with breathing, which is life-threatening. Patients will often be taken into surgery for an emergent escharotomy in cases that affect most or all the circumference of the torso. While most torso escharotomy cases are performed urgently or emergently, ventilators and other breathing devices provide extra time for patient stabilization and improves overall outcomes after escharotomy.

 

The concept behind an escharotomy is that dead, inelastic eschar is removed and healthy (or at least non-eschar) skin is left to re-epithelialize the burned area. In escharotomy, often the burn is so extensive that simple escharotomy is not enough. The eschar is removed and the dissected area requires skin graft or synthetic skin materials to be placed over the wound to promote skin regrowth. Given the emergent nature of an escharotomy, the skin grafting or replacement process often occurs as a second (or several future) surgery. The goal of escharotomy in the short term is to prevent or interrupt compartment syndrome or to prevent compromise of the breathing muscles, ribs, and overall lung function.

 

Escharotomy is not entered into lightly. Having eschar as a covering against bloodstream infection after a burn is better than completely exposed tissues, which is the case after escharotomy. Even with sterile dressings, there is no substitute for skin. That said, an echar is far from natural skin and will be removed if it compromises limb or organ function or viability. Generally the threshold to perform escharotomy of the torso is lower than it is for a limb. In other words, circumferential burns of the torso are subject to escharotomy with less hesitation than eschar affecting the limbs. For escharotomy of an arm or leg, generally doctors will determine of compartment syndrome is occurring or very likely. Compartment syndrome is diagnosed by taking pressure readings inside of the various compartments within the limb. For example, the lower leg has four separate compartments bordered by thick fascia. If the pressure transducer placed into one of these compartments shows a reading of a sufficiently high pressure, an escharotomy is likely to soon follow. In certain cases, a fasciotomy is required to release the pressure from within the compartments, thus sparing the limb. The escharotomy and fasciotomy can be surgically closed at a later point when the pressure and constriction has subsided.