Burns
Kenneth D Boffard in Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
In any trauma resuscitation, the purpose is to combat shock, defined as tissue hypoxia inadequate to the needs of that tissue's survival. Burns are no different, but they present with some special challenges, particularly when the airway is compromised, or when circumferential full-thickness burns with a thick, unyielding eschar produce a tourniquet effect. This can occur around the chest, neck or limbs, producing a slow asphyxiation or critical limb ischaemia. Recognition of the need for escharotomy is vital and needs to be acted upon, usually within the emergency department. An escharotomy is indicated for relief of pressure in a limb or torso to allow vascular supply or ventilation. Circumferential deep limb burns with large overall burn area requiring large volume fluid resuscitation is the commonest scenario. The eschar does not expand to accommodate, and so fluid accumulates, and pressure rises. This process takes some time to reach a crescendo – some 6–8 hours. In an awake patient, the same symptoms and signs as a tight plaster cast are complained of: increasing, unbearable, deep aching pain, loss active muscle movement, extreme pain with forced stretching of muscle groups, cool digits, slowed capillary refill, and loss of digital Doppler signal. The feel of a limb that needs escharotomy can be likened to squeezing an apple- no give. It is common for limbs to be firm, but if there is ‘give’, escharotomy is not (yet) indicated. If pulses are lost and there is still ‘give’ to palpation, first check another limb and the blood pressure. Hypovolaemia may be the cause.
Injuries Due to Burns and Cold
Ian Greaves, Keith Porter, Jeff Garner in Trauma Care Manual, 2021
Escharotomies are needed only if there is circulatory or ventilatory compromise, which does not usually occur until several hours after the injury, as the oedema increases—this means that it is a procedure rarely necessary outside of a specialist burns unit. It is also rarely necessary for a non-specialist doctor to carry out escharotomy but, if it is, it should not be undertaken without prior discussion with the eventual receiving burns centre. Sufficient anatomical knowledge to site the escharotomy incisions avoiding superficially located nerves, such as the ulnar nerve, is essential (Figure 27.6). Escharotomy involves incisions into unburnt tissues and bleeding may be heavy. Electrocautery must be available. Appropriately equipped and resourced burns centres may proceed directly to total early burn excision, thereby eliminating the need for separate escharotomy.
General principles of resuscitation and supportive care: Burns
David E. Wesson, Bindi Naik-Mathuria in Pediatric Trauma, 2017
Circumferential full-thickness injuries can lead to constrictive physiology. In the extremities, full-thickness wounds can swell, compromising arterial and venous blood flow. This decreased blood flow can lead to tissue ischemia and tissue loss. Full-thickness burns to the chest can lead to a restrictive pulmonary physiology, resulting in hypercapnia, hypoxia, and respiratory failure. Escharotomy or linear division of the burn wound can improve vascular flow and mobility and limit tissue loss. Escharotomy incisions are made to the level of the hypodermis to span the length of the affected region, generally on opposite sides of the affected area. Because of the depth of the injury requiring escharotomy, this procedure can be performed with minimal additional analgesics using conventional diathermy.
Enzymatic debridement: past, present, and future
Published in Acta Chirurgica Belgica, 2022
Ignace De Decker, Liesl De Graeve, Henk Hoeksema, Stan Monstrey, Jozef Verbelen, Petra De Coninck, Els Vanlerberghe, Karel E. Y. Claes
Surgical escharotomy for BICS may sometimes be delayed because of logistical shortcomings or even avoided due to its invasiveness, especially by inexperienced surgeons on the other hand it is sometimes performed although not necessary. A safe, non-surgical debriding tool that offers early burn eschar removal on admission, releases (or prevents) BICS with increased preservation of native dermis and/or subcutaneous tissue over the intricate tendinous and vascular structures may provide a minimally invasive modality. It has been proven that already 30 min after employing enzymatic debridement, the compartment pressure decreases below 30 mmHg [86]. This reduction will stand even after removing the product. Fischer et al. reported on the use of NexoBrid® for preventing the need for and morbidity of operative escharotomy [37].
Ecthyma gangrenosum of the eyelid in an immunocompromised patient
Published in Orbit, 2021
Natalie A. Homer, Aliza Epstein, Paul M. Hoesly
Ecthyma gangrenosum is a rare complication of pseudomonas bacteremia, primarily affecting immunocompromised patients, but may also be found in children and immunocompetent adults. Lesions may affect the face in 6% of cases, and initially appear as painless red macules and progress to induration, bullae and eventual gangrenous ulceration. Herein we report the fifth case to affect the periorbital area. Management includes surgical debridement and escharotomy, followed by systemic antibiotic therapy. The wound may be allowed to heal by granulation or be managed with delayed reconstruction following bacterial eradication. Ecthyma gangrenosum should be considered in cases of periorbital necrosis, particularly in immunocompromised patients and those with pseudomonal sepsis.
Enzymatic debridement of hands with deep burns: a single center experience in the treatment of 52 hands
Published in Journal of Plastic Surgery and Hand Surgery, 2020
Mehran Dadras, Johannes M. Wagner, Christoph Wallner, Alexander Sogorski, Maxi Sacher, Kamran Harati, Marcus Lehnhardt, Björn Behr
The first 20 hands were treated 2014–2016 with 13 of them being deep partial thickness burn depth. Of these, 10 (69.2%) received operative intervention with skin transplantation after a median of 3 days post debridement. Of the 25 hands with deep partial thickness burns treated 2017–2019, only four (16%) received operative intervention after a median of 14 days post debridement. Overall, 21 out of 24 hands (87.5%) treated 2014–2016 but only 11 out of 28 hands (39.3%) treated 2017–2019 received surgery (p = .001). No escharotomy was needed in any of the treated hands.