Escharotomy & Compartment Syndrome in Burns

Meet the patient

A 52-year-old man is admitted to the ICU after a house fire with a 45 per cent TBSA flame burn that is circumferential and full-thickness across the entire anterior and lateral chest and upper abdomen. He was intubated for inhalation injury and is ventilated in volume-control mode. Forty minutes into the Parkland resuscitation, the peak airway pressure climbs from 28 to 52 cmH2O, the exhaled tidal volume falls to 250 mL, and the SpO2 drops to 88 per cent.^[1]

The chest is firm, hard and unyielding to palpation. This is not a ventilator problem and it is not a lung problem — it is the rigid circumferential eschar acting like a plaster cast around the thorax. The intervention is not a ventilator adjustment; it is a scalpel.^[1]

The escharotomy is a bedside emergency performed on the ICU or the burns unit — not the operating theatre. The diagnosis is clinical; the release is surgical; the delay is the amputation, the nerve damage, the respiratory failure. The intensivist must recognise the circumferential full-thickness burn, anticipate the swelling from fluid resuscitation (the fluid creep), and incise the eschar BEFORE perfusion is lost. The escharotomy and the fasciotomy are two DIFFERENT operations for two DIFFERENT pathologies — the escharotomy cuts the leathery skin, the fasciotomy opens the deep fascial compartments — and the burn patient often needs BOTH.^[1]

References11ShowHide

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