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102
Dorsal incision
Thenar muscle
Hypothenar
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CHAPTER12 Escharotomies
Fasciotomy
Preferably carried out within 6 hours of the initial injury. The indications are
similar to escharotomy; however, in the case of electrical injury or exceptionally deep circumferential thermal injury a fasciotomy is preferred. The
typical signs of compartment syndrome (pain, pallor, paraesthesia, paralysis,
and pulselessness) are sometimes dicult to assess in the acute stages after
admission due to mechanical ventilation and sedation. Loss of pulse is a late
nding in compartment syndrome. However, if possible, these should be
checked regularly as any changes can give rise to the need for intervention.
Upper limbs
Forearm
Dorsal
Incision is longitudinal and may be linked to the dorsal hand incisions as
per the diagram. It is important to release all compartments in the hand
(Fig. 12.5).
Dorsal incision over
th
metacarpal
4
over 2nd metacarpal
Palmar
interossei
muscle
muscle
Fig.12.5 Fasciotomies of the hand showing release of dorsal and palmar interossei.
Lateral and medial incisions to release thenar and hypothenar muscles respectively.
Adapted from Green DP, et al. (eds). Green’s operative hand surgery, 5th edn. Philadelphia,
PA:Churchill Livingstone, Copyright © 2005, with permission from Elsevier.
Palmar incision
st
1
dorsal
interossei
muscle
Adductor
pollicis
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Volar
Use an ‘S’- shaped skin incision (Fig. 12.6).
• Starting point:between the hypothenar and thenar eminences
• Wrist and distal forearm:decompress the carpal tunnel ± Guyon’s canal
• Turn incision to ulnar aspect of wrist and continue along the ulnar
border of the distal forearm
• Mid- forearm:turn the incision to the radial side of the forearm and then
return to the ulnar border radial to the medial epicondyle
VOLAR
103
Fig.12.6 Markings for fasciotomy of the upper limb.
Adapted from Green DP, et al. (eds). Green’s operative hand surgery, 5th edn. Philadelphia,
PA:Churchill Livingstone. Copyright © 2005, with permission from Elsevier.
104
artery and veins
and tibial nerve
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CHAPTER12 Escharotomies
Proximal forearm and arm
Passing volar to the medial epicondyle the incision then passes proximally
into the arm along the medial border.
Aims
• Decompression of medial and ulnar nerves
• Decompression of supercial and deep compartments of forearm
• Exposure and adequate coverage of the median nerve
• Protection of cutaneous nerves and preservation of as many cutaneous
veins as possible
Pitfalls
Inadequate decompression of compartments of the hand resulting in necrosis of intrinsic muscles.
Lower limb
Although the skin incision is the similar for an escharotomy and fasciotomy
below the knee, the markings for the latter in an adult are approximately
two ngerbreadths either side of the subcutaneous border of the tibia
(Fig. 12.7).
Anterolateral incision
Subcutaneous
tibial border
Anterior tibial
artery and vein
and deep
peroneal nerve
Peroneal
Anterior compartment
Peroneal compartment
Fig.12.7 Cross- section of the leg showing the release of all four compartments.
Here we see entry into the anterior compartment and then subsequent release of
the lateral compartment.
Reproduced from BOA and BAPRAS Standard for Trauma, Copyright © 2009.
Deep posterior compartment
Supercial posterior compartment
Posteromedial
incision
Posterior tibial
artery and vein
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PROXIMAL FOREARM AND ARM
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106
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CHAPTER12 Escharotomies
Anterior incision
Through the skin and fascia into the anterior compartment. The dissection
should then be carried laterally and through the intermuscular septum into
the lateral compartment.
Medial incision
Through the skin and fascia into the supercial posterior compartment, the
Soleus muscle then needs to be dissected free of the medial border of
the tibia allowing continued dissection through the posterior intermuscular
septum in order to decompress the deep posterior compartment.
The importance of decompressing all four compartments completely
cannot be over expressed. Inadequate decompression results in signicant
morbidity and occasionally amputation.
Thigh fasciotomies can be continuous with the incisions below the knee.
The medial incision will allow decompression of the medial compartment
of the thigh. The lateral incision will allow direct access and decompression
of the anterior compartment from which the posterior compartment of the
thigh can be easily accessed (Fig. 12.8).
Pitfalls
Beware of concealed compartment syndrome within the thigh (pain on
passive extension/ exion at knee) prophylactic escharotomy/ fasciotomy is
low risk to prevent signicant risk of distal loss of function.
artery and vein
artery and vein
nerve
compartment
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ANTERIOR INCISION
Profunda
Femoral
Femoral
nerve
Medial
compartment
compartment
Posterior
Sciatic
Femur
Anterior
Fig.12.8 Cross- section of the thigh showing medial and lateral fasciotomies.
Reprinted from Velmahos GC, etal. Vascular trauma and compartment syndromes. Surgical Clinics
of North America 2002;82(1):125– 41. Copyright © 2002 W.B. Saunders Company, with permission
from Elsevier.
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108
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CHAPTER12 Escharotomies
Further reading
Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. Journal of Burn Care &
Research 2009;30:759– 68.
Velmahos GC, Toutouzas KG. Vascular trauma and compartment syndromes. Surgical clinics of
North America 2002;82:125– 41.
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Chapter13
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Critical care ofburns
patients
Denition of critical care of burns patients 110
Airway 111
Breathing 112
Circulation 113
Sedation and analgesia 113
Exposure 114
Fluids 114
Gastrointestinal 114
Infection 114
Ventilator-acquired pneumonia 114
Vascular line infection 115
Metabolic 115
Pharmacy 115
Renal 116
Further reading 116
110
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CHAPTER13 Critical care ofburns patients
Definition ofcritical care ofburns
patients
The management of critically ill burns patients requires close collaboration
between burns surgeons, critical care physicians, microbiologists, pharmacists, and physiotherapists in order to optimize survival of such patients.
Patients with burn injury should be admitted to a Critical Care with burns
expertise for joint Critical Care/ Burns team management in the following
circumstances:
• Inhalational injury requiring mechanical ventilation
• Extensive head/ neck/ chest burns requiring mechanical ventilation
• Requirement for extensive burns surgery
• Management of acute renal failure due to rhabdomyolysis
Survival of critically ill patients in general has continuously improved following the application of evidenced- based treatments, especially mechanical ventilation and these treatments should be considered for all burns
patients.
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Airway
The endotracheal tube in a patient with burns must be left uncut to accommodate facial swelling.
Inhalational injury
• Suspected from the history and examination
• Look for evidence of nasal hair singing, soot in oropharynx, hoarse voice
• Chest X- ray is poor at predicting the presence of inhalational injury
• Bronchoscopy has a major role in the diagnosis of inhalational injury
• Perform bronchoscopy as soon as the patient is admitted to the critical
care unit
• Bronchoscopy ndings may include soot deposits, erythema, mucosal
oedema, mucosal ulceration and incidental presence of pneumonia
• Lavage of lungs with up to 250mL of 0.9% sodium chloride will help to
remove soot plaques
Tracheostomy
For patients who require ventilatory support or airway protection for a
considerable time then a temporary tracheostomy is often required.
Benets
• Much less irritant than oral endotracheal tube
• Patient can be awake and mechanically ventilated without the need for
sedatives
• Permits patient communication, eating and earlier mobilization
• Percutaneous technique with bronchoscopic control can be performed
on intensive care unit
• Relatively safe procedure
Risks
• Presence of burns around the neck or abnormal distorted anatomy may
mean that a surgical tracheostomy is required
• Despite several recent trials, there is no current evidence between an
early versus later tracheostomy in terms of mortality or morbidity
• Haemorrhage during procedure
• Infection around tracheostomy site
• Scarring
AIRWAY
111
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