LRH · EMERGENCY DEPARTMENT

Escharotomy

INDICATIONBurns only. Limb hypoperfusion or ventilation restriction from inelastic burn eschar — can occur with circumferential and non-circumferential burns. Not for non-burn causes of compartment syndrome (those need a fasciotomy). No single test decides this — it's a serial-examination clinical call. Consult the burns service before cutting whenever time permits.

EQUIPMENT
TRAUMA CART · ESCHAROTOMY / BURN KIT
  • Scalpel (No. 10/20 blade) and/or electrocautery with cutting+coag — cautery preferred for hemostasis
  • Antiseptic prep, sterile drapes, marking pen — draw the lines before you cut
  • Artery forceps, gauze, topical hemostatics — released eschar edges bleed
  • Analgesia/sedation: full-thickness eschar itself is insensate, but the margins are not
  • Aftercare: petroleum gauze, topical antimicrobial (e.g. silver sulfadiazine or antibiotic ointment), burn dressings
FIG 1 · ESCHAROTOMY LINES
STEPS
  1. Mark the incision lines with the limb in anatomical position.
  2. Incise through the full thickness of eschar DOWN TO SUBCUTANEOUS FAT ONLY — not fascia (that's a fasciotomy) — until the wound edges visibly spring apart.
  3. Extend each incision at least 1 cm into unburned skin at both ends.
  4. Limbs: mid-lateral AND mid-medial longitudinal lines; carry across joints (tension is greatest there), avoiding flexor creases where possible.
  5. Structures to avoid: ulnar nerve at the medial elbow, common peroneal nerve at the fibular neck, posterior tibial bundle behind the medial malleolus; preserve superficial veins where possible.
  6. Hands: extend to the thenar/hypothenar eminences; digital mid-lateral incisions only if hand surgery unavailable — discuss first.
  7. Chest (“breastplate”): bilateral incisions along the anterior axillary lines from ≈2nd rib to the costal margin, joined by a transverse subclavicular line and a transverse upper-abdominal line — creates a mobile plate so the chest can move.
  8. Endpoint: edges gape, distal perfusion/Doppler returns, ventilation pressures fall. If not — deepen or extend, reassess for fasciotomy need.
  9. After: hemostasis (cautery/forceps), petroleum gauze + topical antimicrobial, elevate the limb, neurovascular checks at least hourly, transfer to the burn center.
Too shallow doesn't release; too deep hits fasciotomy-level structures and nerves. Missing the second line is common — limbs usually need BOTH mid-lateral and mid-medial incisions to adequately decompress.
>30 mmHg
COMPARTMENT PRESSURE TRIGGER
≥1 cm
INTO UNBURNED SKIN, BOTH ENDS
SUBCUT FAT
DEPTH — NOT FASCIA
HOURLY
RECHECK DISTAL PERFUSION
LIMB / VENT
INDICATIONS