Escharotomy: Everything You Need to Know

A procedure that relieves swelling under the skin

An escharotomy is a surgical procedure that is done on a semi-emergency basis to relieve pressure in the torso or a limb that is caused by an eshar, a thickening of the skin that develops due to a burn and can cause significant swelling. The procedure is done to prevent circulation issues, tissue damage, and even tissue death that can result. Generally, an escharotomy is done within a few days after a severe burn, but it isn't usually done immediately.

Surgeons performing surgery in operating room
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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 on 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, general anesthesia is more likely to be used.

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.

Contraindications

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

Potential Risks

An escharotomy can cause complications beyond those related to surgery and anesthesia in general.

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

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.

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.

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 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.

The tight restriction that results from a burn can be relieved with escharotomy because the skin is cut to relieve the pressure that's interfering with blood flow. In a case of already necrotic tissue, an escharotomy aims to salvage as much tissue as possible and to avoid further complications.

Generally, an escharotomy is done within 48 hours of a severe burn to help manage these concerns.

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

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

Burns that damage deep layers of skin, affect more extensive areas of skin, or extend around the limbs or torso are more likely to cause edema and severe tissue restriction, prompting a need for this surgery.

How to Prepare

A safe escharotomy and recovery depend on the optimal management of complications and concerns related to your burn before the procedure is done.

This includes medical stabilization and management of coexisting health issues such as:

Many of these medical problems can rapidly fluctuate within the first few days of a severe burn. The timing of your escharotomy in relation to the treatment these issues will be tailored to your specific situation.

You will likely have blood tests and imaging prior to an escharotomy.

Location

You will have your escharotomy procedure in a surgical operating room of the hospital you are already admitted to for burn care.

This procedure is sometimes done in an emergency ward if needed.

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 unexpectedly, such preparation might not be feasible.

Medications

Before your escharotomy, you might receive medication to reduce your edema, such as steroids or diuretics. Be sure to tell your care team about any medications you were taking prior to being admitted to the hospital, if you haven't done so already.

What to Expect on the Day of Surgery

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.

Your surgery will take several hours; it could be longer if you have a large area of skin damage.

Before the Surgery

You should already have an intravenous (IV, in a vein) line in your hand or arm during your hospital stay; a new one will not need to be placed.

A surgical drape will be placed over your body leaving the skin that will be surgically treated 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. In this case, you would receive IV medication to make you sleep. A breathing tube would be placed in your throat to provide you with mechanical breathing assistance during your surgery.

During the Surgery

Your surgeon will locate the area of your limb or torso that is restricted. They may palpate (gently press) the area to identify stiff parts 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.

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.

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

Your bleeding will be closely controlled during your procedure. Generally, the surgical wound is not closed with stitches, but 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 the 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 had your escharotomy and other burn areas as well.

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

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. You will be discharged from the hospital to go home when you are medically stable.

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 frequent visits with your doctor and follow-up care. At these appointments, your dressing will be changed and your surgical team may place topical antibiotics on your escharotomy wound.

You might need to have more than one procedure (which may or may not be related to your escharotomy), such as repair of bone fractures or surgical intervention for a blood clot.

Healing

If you experience pain, you can take pain medication as instructed. You may also have a prescription for oral or topical antibiotics, and it's essential that you use them as recommended to avoid an infection.

Caring for your wound is critical and includes keeping it clean and dry, but also monitoring for signs of concern. Be on the lookout for potential signs of complications and call your doctor if you experience any, such as:

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

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

Coping With Recovery

Try your best 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 getting some physical activity to avoid issues that can occur when you are too sedentary, such as pressure ulcers, muscle atrophy (thinning), and blood clots. Though you may not feel motivated to get moving, doing so is an important part of the healing process.

Long-Term Care

You can heal from your burn, but you may have a persistent scar. This area can be prone to sunburn or 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 accidents and 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

Generally, an escharotomy is done as a one-time procedure to prevent damage from a burn-induced limb-threatening or life-threatening eschar.

After surgery, the wound might heal with little alteration in physical appearance, but your post-recovery scar can be substantial. If this is concerning to you, discuss it with your doctor. Reconstructive surgery, such as a skin graft, may be possible 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. Having an open conversation with your medical team about what you can and cannot expect can help you better prepare for the road to recovery.

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