What should be done for a patient with a circumferential burn to the arm, presenting with paresthesia and pain?

Management of Circumferential Arm Burn with Paresthesia and Pain

This patient requires immediate referral to a burn center, where escharotomy will be performed if indicated—escharotomy should NOT be performed outside a specialized burn center unless transfer is impossible and specialist consultation has been obtained. 1

Immediate Clinical Assessment

The presence of paresthesia and pain in a circumferential burn indicates impending or established compartment syndrome, which can rapidly progress to acute limb ischemia with neurological disorders and downstream necrosis. 1, 2 This represents a time-sensitive emergency requiring urgent action.

Key clinical signs to assess immediately:

• Evaluate for the "6 Ps": Pain (especially out of proportion), Pallor, Paresthesia (already present), Paralysis, Pulselessness, and Poikilothermia 3
• Palpate compartments for tightness and assess distal neurovascular status 2
• Check pulse oximetry (target >90%) and Doppler flow in the affected extremity 4
• Measure compartment pressure if equipment available (>30 mmHg indicates compartment syndrome) 3

Critical Management Algorithm

Step 1: Immediate Burn Center Contact

Contact a burn specialist immediately via telemedicine or phone to:

• Confirm the diagnosis and severity 2, 5
• Arrange direct transfer to a burn center 1
• Obtain guidance on temporizing measures during transport 1

Direct admission to a burn center (rather than sequential transfers) significantly improves survival, reduces morbidity, and enables earlier surgical intervention. 1

Step 2: Pre-Transfer Stabilization

While arranging transfer:

• Administer titrated intravenous opioids or ketamine for pain control, as burn pain is often intense 5
• Remove all jewelry and constrictive items immediately to prevent further vascular compromise 6
• Elevate the affected extremity 4
• Monitor pulse oximetry and Doppler flow hourly 4
• Cover the burn loosely with clean, non-adherent dressing 6

Step 3: Escharotomy Decision—Only at Burn Center

Escharotomy should be performed ONLY at a burn center because:

• Poorly performed escharotomy is associated with increased morbidity 1, 2
• Significant complications include hemorrhage and infection 1
• Specialized burn centers have the expertise and resources to manage complications 1

Exception: If transfer to a burn center is impossible and the patient exhibits progressive circulatory impairment (absent pulses, oximetry <90%, progressive neurological deterioration), obtain specialist telemedicine consultation before attempting escharotomy. 1, 2

Critical Timing Considerations

Escharotomy is rarely indicated immediately except for compromised airway movement/ventilation. 1 However, patients with circulatory impairment should undergo escharotomy within 48 hours of symptom emergence. 1

Important caveat: Delaying decompression while waiting for complete pulse loss can result in irreversible damage within 6-8 hours. 2 The presence of paresthesia already indicates nerve compromise and demands urgent action.

Alternative Consideration (At Burn Center Only)

Recent evidence suggests enzymatic debridement with Nexobrid® (bromelain-based) can reduce compartment pressure by approximately 60% within 1 hour of application, potentially obviating the need for surgical escharotomy in selected patients. 7, 3, 8 However, this:

• Must be applied within 12 hours of injury 8
• Requires specialized burn center protocols 7, 3, 8
• Is contraindicated in established compartment syndrome, electrical injuries, or burns requiring fasciotomy 8
• Should not delay transfer or surgical escharotomy if immediately indicated 7

Critical Pitfalls to Avoid

• Never delay transfer to a burn center for any circumferential burn with neurovascular compromise—this increases mortality and morbidity 1, 2
• Never perform escharotomy outside a burn center unless transfer is impossible and specialist consultation obtained 1, 2
• Never wait for complete pulse loss before acting—paresthesia indicates nerve ischemia already occurring 2, 3
• Never rely solely on Doppler flow—patients with negative Doppler but oximetry >90% may not require immediate escharotomy, but those with positive Doppler and oximetry <90% do require intervention 4