Escharotomies, Fasciotomies and Carpal Tunnel Release in Burn Patients - Review of the Literature and Presentation of an Algorithm for Surgical Decision Making

Abstract

Escharotomies are usually performed in patients with circumferential third degree burns of the extremities or anterior trunk. Fasciotomies are recommended for patients who sustained high voltage (or associated crush) injuries, with entrance or exit wounds in one or more extremities. Carpal tunnel release is practiced routinely in some services for cases of electrical injury. We have reviewed the literature which provides relatively little information as to when should these procedures actually be performed and what would happen if they were not done. We present a series of patients treated at our institution when an algorithm was used for surgical decision making as to when (or not) to operate (perform an escharotomy, a fasciotomy or a carpal tunnel release), based on clinical signs and monitoring alternatives, using the oximeter and the Doppler flowmeter. 13 938 burn patients were treated at our institution during the year of 2005. Of these, 571, with an average of 22.3 % TBSA, were treated as inpatients. Of these, 58 (10.3 %) had circumferential or electrical burns of one or more extremities. Patients were monitored hourly from admission and decision to operate was based on clinical signs and in absent or below 90 % oximetry, regardless of Doppler flow signs. 68 % were males, 6 (11.3 %) patients had immediate escharotomies, while 4 (7.5 %) had immediate fasciotomies. 2 of these patients were operated regardless of positive Doppler sign but no oximetry. All patients recovered oximetry over 90 % immediately after the operations. 3 patients had negative Doppler sign but oximetry > 90 % and were not operated. 3 patients had carpal tunnel releases based on oximetry < 90 % and symptoms of compression of the median nerve. Patients who were not operated fared well with no signs or symptoms of impairment of circulation or nerve damage up to their 3 and 6 months reevaluations.

A review of the burns caseload of a physician‐based helicopter emergency medical service

“…This treatment algorithm resulted in no long‐term deficit in those falling outside the criteria for escharotomy. Conversely, significant negative outcomes have resulted from delay in escharotomy or inadequate decompression through incorrect technique . Early intervention is key to preventing permanent deficit, before the loss of peripheral pulses, when significant damage may have already occurred …”

“…Conversely, significant negative outcomes have resulted from delay in escharotomy or inadequate decompression through incorrect technique. [9][10][11] Early intervention is key to preventing permanent deficit, before the loss of peripheral pulses, when significant damage may have already occurred. [9][10][11][12] Escharotomies were appropriately performed by GSA-HEMS in eight cases, often by physicians performing the procedure for the first time.…”

Burns

“…31 In addition, the use of compartment pressure monitoring either in the limb or intraabdominally is a priority if there is any question about the diagnosis. Fasciotomy must be considered in patients who have sustained high-voltage injuries, those with associated crush injury and those with very deep burns involving fascia and muscle.…”

Atendimento inicial às queimaduras de mão: revisão da literatura

“…Em geral, uma incisão por dedo é suficiente. Caso esse procedimento seja realizado de forma tardia, pode haver problemas circulatórios, lesões nervosas, necrose muscular e perda funcional [2,15,16].…”