EMERGENCY DEPARTMENT · WALL POSTER

Escharotomy

DECIDEBurns only: limb hypoperfusion or restricted ventilation from inelastic eschar. · Limb: pulses fading, pressure >30 mmHg, deficit progressing. Torso: rising peak pressures. · No test decides this. Consult the burn service before cutting whenever time permits.

STEPS · ◆ KEY STEP — LOGGED WITH ITS TIME

TECHNIQUE — STEP BY STEP

Mark the incision lines with the limb in anatomical position.
Incise the full thickness of eschar down to fat only — do not cut the fascia. Edges should spring apart. ◆ ESCHAROTOMY INCISED
Extend each incision at least 1 cm into unburned skin at both ends.
Limbs: mid-lateral and mid-medial lines, carried across joints.
Avoid: ulnar nerve at the elbow, peroneal at the fibular neck, posterior tibial behind the malleolus.
Hands: extend to the thenar and hypothenar eminences.
Chest: bilateral anterior axillary lines, joined above and below.
Endpoint: edges gape, Doppler returns, ventilation pressures fall.
After: hemostasis, dress, elevate, neurovascular checks hourly, transfer to the burn center.

EQUIPMENT

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.
Analgesia/sedation: full-thickness eschar itself is insensate, but the margins are not.
Aftercare: petroleum gauze, topical antimicrobial, burn dressings.

IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · PROCEDURE TRAYS

Scalpel No. 10 blade ×1
Scalpel No. 20 blade ×1
Marking pen — draw the lines first ×1
Artery forceps ×2
Topical hemostatic gauze ×1
Gauze packs ×6
Antiseptic prep + sterile drapes ×1
Petroleum gauze + burn dressing — aftercare ×1

ALSO NEEDED — NOT IN THE KIT

Electrocautery with cutting and coag is preferred over the scalpel for hemostasis and lives on the unit, not in the bag. Analgesia and sedation from the Omnicell.
DRAFT — not yet assembled or signed off. Draw the lines before you cut. Have the hemostatics open first.

FIGURE

Cut through eschar only, until it gapes and distal perfusion (or chest excursion) returns — avoid named nerves at the elbow/wrist/fibular head.

COMPARTMENT PRESSURE TRIGGER >30 MMHG

EXTEND ≥1 CM INTO UNBURNED SKIN, BOTH ENDS

DEPTH: THROUGH ESCHAR TO SUBCUT FAT — NOT FASCIA

RECHECK DISTAL PERFUSION AT LEAST HOURLY

PITFALLS & PEARLS

Too shallow (does not release) or too deep (fasciotomy-level structures, nerves).

Missing the second line.

Cutting over the ulnar or common peroneal nerves or the malleolar bundles — mark the lines first.

Underestimating the bleeding once perfusion returns.