Escharotomy

After our last post, a few viewers have suggested that we continue the trend of elevated compartment pressures and address a super duper rare yet potentially life saving procedure today.   So, escharotomy....here-a we go!

Let's say you have a patient brought in from a fire with full thickness burns to their torso.  You intubate, start hydrating per the Parkland Formula, and you (assuming you are not one) get your burn center on the horn.  Your respiratory tech suddenly notes that they are having an incredibly difficult time ventilating patient, and their peak pressures are shooting off the charts.  Your trauma surgeon is not readily available, but you need to do something now.  

It's time for escharotomy, as the full thickness burns are causing chest wall constriction.  Eschars can also cause peripheral arterial occlusion (not unlike compartment syndrome!), and tracheal compression as well. 

The pressure needs to be released in a fasciotomy-like release, and almost always this should be done in an operating room--if there's time.  The procedure itself really does creep outside of the scope of our practice, and really should only be done in absolutely dire circumstances, mainly airway compromise and severe limb ischemia.  

To prepare, you will mainly need some antiseptic prep and a scalpel.  It will be handy to have electrocautery (cutting diathermy for the skin and coagulative diathermy for bleeding) available as you may encounter some significant bleeding.

The incisions to the chest should start at the clavicles at the anterior axillary line and extend inferiorally, down to the subcutaneous fat.  You'll want to connect these lines with a transverse incision in the upper abdomen (the so-called "Roman Breast Plate"). If your pressures were significantly elevated you should see notable separation between the wound edges. If it's indicated, extremities can be incised in a similar manner along medial and lateral mid-axial longitudinal lines as depicted below.  You'll want to avoid any extensor or flexor creases.

If the burns are full thickness, the skin should be insensate but local anesthesia may be indicated if there's a question if it's partial thickness or not.  Overall optional as your patient is hopefully intubated and sedated at this point, and you may not have the time.

A very creative, MacGyver-esque simulation model can be seen here courtesy of Greater Sydney Area Helicopter Emergency Medical Service.

As always, these procedures are meant for medical professionals, and are for EDUCATIONAL PURPOSES ONLY.  All efforts should be made for this one to be done in a controlled, operative setting with trained sub-specialists, and not in your shop.

Sources:

Roberts and Hedges Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 38.

Life in the Fast Lane Blog - "Releasing the Roman Breastplate"