Treatment of Circumferential Burns
Escharotomy is the primary treatment for circumferential third-degree burns causing compartment syndrome, and should be performed at a specialized burn center whenever possible to reduce morbidity and mortality. 1
Understanding Circumferential Burns
- Circumferential third-degree burns can induce constriction, increasing pressure inside the affected anatomical compartment 1
- This pressure can lead to acute limb ischemia with neurological disorders and downstream necrosis 1
- It can also cause thoracic or abdominal compartment syndrome with decreased cardiac output, reduced pulmonary compliance, hypoxia, hypercapnia, acute renal failure, and mesenteric ischemia 1
Initial Management
- Transfer the patient to a specialized burn center whenever possible, as these centers are associated with better survival rates and decreased morbidity 1
- Remove any jewelry from the affected area before swelling occurs to prevent constriction and vascular compromise 2
- Administer appropriate pain medication such as acetaminophen or NSAIDs 3, 2
- Monitor for signs of compartment syndrome including increased pain, paresthesia, pallor, pulselessness, and paralysis 1
Escharotomy Procedure
- Escharotomy can decompress the subcutaneous tissue in cases of third-degree (and sometimes deep second-degree) circumferential burns 1
- While rarely performed, escharotomy decreases intra-compartmental pressure and can both cure and prevent compartment syndrome 1
- This procedure should be performed only at a Burns Centre by experienced personnel 1
- If transfer to a burn center is impossible, specialist advice should be obtained before performing an escharotomy 1
Timing of Escharotomy
- Escharotomy is rarely indicated immediately after injury 1
- The only urgent indication is compromised airway movement and/or ventilation 1
- Patients with intra-abdominal hypertension or circulatory impairment should undergo escharotomy within 48 hours of the emergence of these conditions 1
Alternative Approaches
- For select cases of circumferential deep burns of the distal upper extremity, enzymatic debridement with agents like Nexobrid may prevent the need for operative escharotomy if applied within 12 hours of injury 4
- This approach should only be considered when there is no clinically established compartment syndrome, and for patients without contraindications to enzymatic debridement 4
Complications and Risks
- Escharotomy carries risks of complications, particularly hemorrhage and infection 1
- A poorly performed escharotomy is associated with increased morbidity 1
- This highlights the importance of having the procedure performed at specialized burn centers by experienced personnel 1
Post-Procedure Care
- After escharotomy, patients require close monitoring for adequate tissue perfusion 5
- Early wound closure and rapid wound coverage are essential to minimize physiologic alterations 6
- Nutritional support in the form of early enteral tube feedings helps decrease the hypermetabolic response 6
Special Considerations
- For circumferential burns to digits associated with rings, immediate removal of jewelry is critical 7
- In cases of superficial dermal burns, conservative treatment with biosynthetic dressings or nanocristalline silver gauze dressings may be appropriate 8
- For deeper burns, split-thickness skin grafts are typically used for wound closure after escharotomy and debridement 8