Escharotomy: Everything You Need to Know

A procedure that relieves swelling under the skin

Surgeons performing surgery in operating room.

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An escharotomy is a surgical procedure that is done on a semi-emergency basis to relieve pressure on the torso or limb-threatening tension caused by an eshar, which is a thickening of the skin that develops due to a burn. Generally, this procedure is done within a few days after a severe burn, but it isn't usually done immediately.

What Is Escharotomy?

An escharotomy is an operation in which an opening is made into an area of skin that is thickened and tightened after a severe burn. Generally, this surgery is done with a surgical knife, but another technique involves the use of an enzymatic treatment that is placed on the skin to chemically remove the damaged skin.

Escharotomy can be done on its own or as part of a more extensive procedure, and you can have an escharotomy for any area of the body that is affected by a burn, such as the face, chest, abdomen, or limbs.

Your procedure will likely be performed by a trauma surgeon or a plastic surgeon.

Pain control is often necessary, and it is usually achieved with local anesthesia. If the escharotomy is part of a more extensive operation, then general anesthesia is more likely to be used.

Contraindications

An escharotomy is contraindicated if the procedure would be expected to cause more damage than benefit. And it is not recommended if the burn is superficial or is expected to heal without this surgical intervention.

Potential Risks

An escharotomy can cause complications beyond the usual complications of anesthesia and surgery.

Problems that can arise due to an escharotomy include:

  • Bleeding
  • An infection
  • Damage to nearby structures or nerves
  • Incomplete release of tension

Your surgical team will monitor you for these complications as you are recovering from your procedure.

Purpose of Escharotomy

Severe burns due to steam or heat exposure, fire, chemicals, or electrical injuries can cause edema (swelling) underneath the skin. Sometimes, the skin can be so tight around the blood vessels, muscles, and tissue that the pressure can cause permanent damage.

This squeezing effect can be even more severe if the skin begins to scar and stiffen. If the swelling continues, blood cannot flow easily, and the underlying tissue becomes starved of oxygen and nutrients. Often, this is accompanied by a feeling of tingling, or sensation can be impaired.

This problem is often referred to as compartment syndrome. Burns that damage deep layers of skin, affect more extensive areas of skin, or extend around the limbs or torse are more likely to cause edema and severe tissue restriction.

The tight restriction can be relieved with escharotomy because the skin is cut to relieve the pressure that's interfering with blood flow.

Necrosis

Without treatment, the tissue may eventually become necrotic (die) within a few hours or a few days, depending on the location and the extent of pressure.

Necrotic tissue is no longer useful for its intended purpose, and it also leads to additional problems, such as infection of nearby tissue. Generally, areas of the body that have become necrotic need further care, including cleaning, debridement, and possibly suture to close open wounds.

An escharotomy aims to salvage as much tissue as possible and to avoid further complications.

How to Prepare

In the days immediately after a major burn, your medical care is very closely controlled and your burn care team will frequently assess your condition to rapidly identify the need for an escharotomy.

Generally, an escharotomy is done within 48 hours of a severe burn.

Criteria used to help determine whether you need an escharotomy include:

  • A compartment pressure greater than 30 millimeters (mm) mercury (Hg) as measured with a manometer (a device that measures pressure against fluid)
  • 6 Ps: Pain, pallor, paresthesia (tingling or unusual sensations), paralysis, pulseless, and poikilothermia (uncontrolled temperature regulation)

You will likely have blood tests and imaging tests prior to your procedure. Within these first few days after a severe burn, you can have many rapidly fluctuating medical issues, such as dehydration, bleeding, and hypotension (low blood pressure).

Your recovery after your escharotomy is dependent on optimal management of the complications that occur right after a burn injury.

You may also have other issues, like bone fractures, organ damage, and chemical injuries that need to be managed along with your burn.

Location

You will have your escharotomy procedure in a surgical operating room. Sometimes, this procedure is done in an emergency ward if needed.

What to Wear

You will likely be an inpatient and already be wearing a hospital gown, and you would need to change into a fresh gown to ensure a sterile environment during surgery.

Food and Drink

It may be recommended that you fast from food and drinks the night before your procedure if it will be done with general anesthesia. But since your escharotomy might be done without advance planning, this type of preparation might not be feasible.

Medications

Before your escharotomy, you might receive medication to reduce your edema, such as steroids or diuretics.

What to Bring

You will likely be in the hospital before your operation, so you would not be able to bring anything specific to the procedure.

Pre-Op Lifestyle Changes

Since escharotomy is a semi-urgent surgery that is done to avoid consequences of a recent burn, there are no lifestyle changes that you need to make.

What to Expect on the Day of Surgery

You will likely be staying in the hospital for burn care when you have your escharotomy.

On the day of your procedure, your surgeon will examine the area of your burn. Your sensation may be tested, and your surgical team will also assess your skin to see if you have extensive bleeding or any evidence of an infection.

You may have blood tests, including complete blood count (CBC) and a comprehensive chemistry panel to assess your need for fluid supplementation or a blood transfusion.

You should already have an intravenous (IV, in a vein) line in your hand or arm during your hospital stay.

Before the Surgery

Before your procedure, you will have the area of skin prepared, and your anesthesia will be started.

A surgical drape will be placed over your body, and the skin that will be surgically treated will be exposed. You will also have your skin cleansed with a surgical cleaning solution.

Your anesthesia team may inject anesthetic medication in your IV to make you drowsy. You may also have local anesthesia placed near your surgical area.

If you are having another procedure at the same time as your escharotomy, such as surgery for positioning of a bone fracture, you might have general anesthesia during your escharotomy. If you are having general anesthesia, you would receive IV medication to make you sleep. And a breathing tube would be placed in your throat to provide you with mechanical breathing assistance during your surgery.

During the Surgery

For your escharotomy procedure, your surgeon would locate the area of your limb or torso that is restricted. Your surgeon may palpate (gently press) the area to identify stiff areas of skin and scarring and to assess your blood flow by feeling your pulse.

Sometimes a manometer is used during surgery to measure pressure and help guide the procedure.

You may have an incision placed in your skin, or you might have your escharotomy done with an enzymatic solution that removes a layer of your skin.

  • If you are having an incision, it may be done longitudinally, horizontally, or in a spiral pattern around the affected area.
  • If you are having an enzymatic escharotomy, the solution will be carefully placed on the area of skin that is producing pressure.

The area of skin that needs to be released will measure about 2 centimeters (cm), and your surgeon will determine the exact location, length, size, and depth of the incision needed to release pressure and prevent necrosis.

Your bleeding will be closely controlled during your procedure. Generally, the surgical wound is not closed with stitches, and it is covered with a surgical dressing for protection.

Once your procedure is complete, your anesthesia will be stopped. If you have general anesthesia, your breathing tube will be removed. And your anesthesia team will ensure that you are breathing comfortably on your own before you go to the recovery area.

After the Surgery

After your procedure, you may go to a postoperative recovery area or back to your hospital room. You may still have swelling after your escharotomy, but you shouldn't continue to be at risk of necrosis.

However, as you are recovering from your burn, your health might continue to be unstable. Your burn care team will continue to monitor you for symptoms of edema in the area where you have had your escharotomy and other burn areas as well.

You may have IV antibiotics if there is a risk of infection, and you may have pain medication as needed.

Once you are medically stable, you will be discharged from the hospital to go home. After a severe burn, your hospital stay can last for days or weeks, depending on the extent of the burn and the severity of the resulting medical issues.

Recovery

Recovery after an extensive burn can take weeks or months. In addition to any medical issues that you are recovering from, you will have to recover from your escharotomy procedure. You will need to follow up with your doctor as directed, and you will also need to take care of your wound.

During your recovery, you might need some at-home care provided by a visiting nurse who may see you every few days to evaluate your wound.

Healing

At home, you will have to care for your wound, This includes keeping it clean and dry. You might experience pain as you are healing. You can take pain medication as instructed.

And you may have a prescription for oral or topical antibiotics. Be sure to use your antibiotics as instructed to avoid an infection.

Signs of complications to look out for include:

  • Fever
  • Warmth of the surgical area
  • Worsening pain
  • More severe numbness or tingling
  • Bleeding
  • Pus
  • A sense of tightness or pressure
  • Swelling

If you experience any of these symptoms, call your doctor.

Coping With Recovery

As you are recovering from your burn, you may need frequent medical visits and follow up care. Recovery from a burn can take time, and you might need to have more than one procedure, some that are unrelated to your escharotomy.

It is important that you try to maintain good nutrition and fluid intake to optimize your recovery. If you are having a hard time eating and drinking, talk to your doctor so you can potentially receive nutritional supplementation to help you build your strength.

You might also be given instructions about moving around to avoid issues like pressure ulcers, muscle atrophy (thinning), and blood clots that can occur due to inadequate movement.

Long Term Care

You will heal from your burn, but you may have a persistent scar. This area can be prone to sunburn, bleeding, or it may be persistently numb or sore.

  • It is important that you wear sunscreen on any areas of your skin that have recovered from a burn.
  • Decreased sensation can be bothersome, but it usually isn't dangerous. However, diminished sensation may predispose you to injuries, so you need to be aware of that and to check this area of skin every day.
  • Persistent pain can be treated with oral or topical medication. Talk to your doctor about the right strategy for pain control. Your pain may continue to improve even years after your escharotomy.

Possible Future Surgeries

After your swelling subsides and your wound heals, you can still have a substantial scar due to your burn. You may discuss your scar with your doctor, and you could consider having reconstructive surgery, such as a skin graft after you recover from your burn.

Lifestyle Adjustments

You will need to take care of your scar to avoid further skin damage, but otherwise, you shouldn't have any activity limitations due to your escharotomy.

A Word From Verywell

An escharotomy is an important procedure that can prevent severe tissue damage after a burn. If you are having this procedure, you may have weeks or even months of healing ahead of you., Local disasters can cause a high volume of injuries. There are several techniques used in escharotomy, and the use of enzymatic solutions has been considered a potential way to treat many people when there is a sudden need for this procedure and a lack of available surgeons who are trained in it.

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