Circumferential deep full thickness burns of an extremity or around the chest or abdomen should be carefully monitored.
KEY STEPS:
- Neurovascular Observations/Breathing Difficulties
- Elevate Affected Areas
- Consider Escharotomy
Check Neuromuscular Observations in Distal Extremities:
Circumferential full thickness burn to leg: cool to touch, loss of circulation and pulse distally
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- Colour and Pulses
- Capillary refill
- Warmth
- Pain
The onset of circulatory compromise is slowly progressive, and escharotomy is not usually required within 6 hours of a burn. Patients with circumferential limb burns which are compromising circulation exhibit:
- Loss of distal circulation and pulses
- Cool limbs
- Numbness or pain
- Reduced peripheral pulse oximetry
These are late signs and escharotomy should be considered when there is evidence of tightness of the eschar. Consultation with ARV and the appropriate Burn Service should occur prior to performing the procedure to minimise risks. Due to the efficiency of the Victorian State Trauma System (average transfer time for severe burn patients is 3.6 hours), the need for escharotomy is uncommon.
Check for Breathing Difficulties – Chest/Abdomen
Circumferential chest burns can restrict chest expansion and breathing
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When the chest wall is extensively burnt, compliance decreases as the eschar prevents chest expansion and hence air entry, and respiration and ventilation maybe compromised. Extensive full thickness abdominal burns can significantly impair ventilation, especially in small children who are predominantly diaphragmatic breathers. Check for:
- Difficulty breathing
- Ventilator high pressure alarm activating
Elevate Affected Areas if Appropriate
- Sit the patient up if appropriate
- Elevate Affected Limbs
This will help to reduce oedema and buy some time.
Consider Escharotomy
Escharotomy maybe indicated when circulation or breathing becomes compromised due to increased pressure caused by the oedema and swelling in the tissue deep to the burn interfacing with the unyielding overlying burnt skin (‘eschar’) which acts like a tourniquet. Escharotomy is a high risk procedure and consultation with ARV and the appropriate Burn Service prior to undertaking the procedure is required to optimise outcomes and minimise risks.
