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Burn Escharotomy
WendyY.Rockne andTheresaL.Chin
100
Burn Escharotomy
Concept
Full-thickness burns result in severely damaged, inexible
dead tissue known as eschar. In the burn-injured patient with
circumferential burns to the neck, trunk, or limbs, this stiff
eschar can cause compromised circulation, unyielding compartments, and/or limited respiratory function, resulting in
immediate threat to life and limb (Zhang etal. 2023). The
general surgeon must be able to promptly recognize and
denitively manage burn-injury eschar via escharotomy to
prevent serious morbidity and mortality in the burn-injured
patient. Escharotomy should be performed after the primary
and secondary survey. Rarely is it necessary to perform
escharotomy during the primary survey.
Indications for Escharotomy
• Circumferential burns of the neck with resulting airway
obstruction.
• Circumferential burns of the chest resulting in respiratory
compromise.
• Circumferential burns of the abdomen with symptoms of
intra-abdominal hypertension and/or abdominal compartment syndrome.
• Circumferential burns of the extremities, with or without
symptoms of muscle compartment syndrome or tissue
ischemia.
• Near-circumferential burns of the extremities with symptoms of muscle compartment syndrome or tissue
ischemia.
General Escharotomy Technique (Gillenwater and
Garner 2020)
• Preserve normothermia.
– Cover the patient as much as possible. Sequentially
uncover, fully release, and redress each affected body
area to avoid full-body exposure and risk of hypothermia.
– Administer pain medication and/or sedatives to the
patient.
• Plan incision to extend just barely beyond the burn into
normal skin.
– Mark out planned escharotomy incisions (if the patient
is stable and time allows).
• Divide through the full thickness of burned skin and
slightly into subcutaneous tissue to separate the dermal
elements.
– Electrocautery is preferred for better hemostasis but
tissue can be divided sharply if emergent and electrocautery is unavailable.
– Deep fascia should not be violated unless a fasciotomy
is necessary.
• Conrm adequacy of the release.
– Return of function/perfusion to the affected area.
– Released area should be diffusely soft without any
focal constrictions.
• Achieve meticulous hemostasis after verifying adequacy
of release.
– Can use electrocautery or suture ligation.
• Subsequently, dress and cover incision sites and burn
wounds.
Complications ofEscharotomy
Escharotomy, when done promptly and adequately, is a sim-
W. Y. Rockne · T. L. Chin (*)
Division of Trauma, Burns and Surgical Critical Care, Department
of Surgery, University of California Irvine Medical Center,,
Irvine, CA, USA
e-mail: Wendy.Y.Rockne@uth.tmc.edu; chintl1@hs.uci.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_100
ple and safe surgical technique with few complications
(Gillenwater and Garner 2020).
Most common complication: inadequate release.
Less common: signicant bleeding from inadequate hemo-
stasis techniques/coagulopathy, injury to underlying
329
330
W. Y. Rockne and T. L. Chin
structures from poorly planned incisions/inadequate
knowledge of surface anatomy.
Common Curve Balls
After escharotomy, function/perfusion is not restored to the
affected body part.
Severe burns can involve the deep fascia. If adequate escha-
rotomies do not restore normal function/perfusion, fasciotomies may be required.
After escharotomy, the underlying musculofascial com-
partments are tight/tense to palpation.
Musculofascial compartments should be soft and compress-
ible to palpation after escharotomy. If underlying musculofascial compartments are tight to palpation after
escharotomy, score the deep fascia to assess for muscle
bulging, indicating the need for fasciotomy. Proceed with
fasciotomies in the standard fashion if indicated.
A patient with an electrical burn injury develops signs/
symptoms of extremity compartment syndrome in a separate, nonburned extremity after you have performed escharotomy for a circumferential burn elsewhere.
Remember that bone has the highest resistance of any body
tissue and therefore generates the greatest amount of
heat when exposed to an electrical current, so the deep
tissues surrounding long bones are often the most heavily
damaged after high-voltage electrical injuries. Because
of this, severe burns and extremity compartment syn-
drome can be incurred without typical external signs of
burn injury. Do not miss the need for decompressive fas-
ciotomy in an electrical burn patient without external
signs!
Clean Kills
• Performing escharotomy prior to performing a primary
and secondary survey.
• Failing to recognize and immediately treat developing
compartment syndrome.
• Neglecting to adequately resuscitate the patient while
determining the need for escharotomy.
• Failure to preserve normothermia.
• Performing incomplete/inadequate escharotomy.
• Missing need for fasciotomy after escharotomy.
Circumferential Burns oftheExtremities
Concept
Circumferential full-thickness burns to extremities require
escharotomy to prevent long-term neurological dysfunction.
Near-circumferential burns of the extremities require close
monitoring so that prompt escharotomy may be performed if
signs of compartment syndrome develop (Cone and Inaba
2017).
How Question May BeAsked?
“A 19-year-old male patient presents to the emergency department with circumferential full-thickness burns to his bilateral
lower extremities after jumping into boiling hot springs while
hiking. First responders state that initially the patient had only
mild pain in his legs, but now is complaining of excruciating
pain in his legs and feet that worsens with movement.”
How toAnswer?
Take a brief history and physical examination while resuscitating the patient
History
• Mechanism of injury involving circumferential burns to
extremities (commonly ame, steam, explosion, submersion injuries).
• History of peripheral arterial disease, diabetes, previous
extremity surgeries (higher risk of neurovascular compromise and abnormal baseline).
Physical Examination
• Primary Survey: Airway, breathing, circulation.
• Secondary Survey: Estimation of Total Body Surface
Area (TBSA), initiation of burn resuscitation.
• Full-thickness circumferential or near-circumferential
burns to extremities. Neurovascular exam of extremities
• Check for the 6Ps: pain, paresthesia, poikilothermia, pallor, paralysis, pulselessness (Cone and Inaba 2017). If
present, escharotomy or fasciotomy are emergent.
Diagnostic Tests
Can be considered, but do not delay treatment for diagnostic
labs, as the need for decompressive escharotomy in cases of
circumferential extremity burns can be determined by physical examination alone.
• Standard labs
• Neurovascular checks, distal pulses/signals of affected
extremity
100 Burn Escharotomy
331
• Compartment pressure check (>30mmHg prompt urgent
escharotomy of affected extremity)
• X Rays to rule out underlying fracture or other traumatic
injury
Treatment
• Elevation of the extremity to reduce swelling.
• Judicious use of resuscitative uids.
Escharotomy oftheLower Extremity (Gillenwater
andGarner 2020; Cone andInaba 2017)
1. Mark incisions along medial and lateral axis of lower
extremity (Fig.100.1)
• Place to avoid damage to underlying supercial structures, including neck of bula (peroneal nerve), popliteal fossa (neurovascular structures), posterior aspect
of medial malleolus (posterior tibial artery and nerve).
• Spare greater/lesser saphenous veins and sural nerve if
able.
2. Perform release along marked incisions sites using electrocautery as previously described.
• Can use scalpel for sharp release if performing emer-
gently at bedside
3. Recheck distal perfusion after release.
• Palpation or transcutaneous Doppler assessment of
dorsalis pedis artery, posterior tibial artery, and plantar
arch
• Nail Bed capillary rell, pulse oximeter on toe
Escharotomy oftheArm andForearm1
(Fig.100.2)
1. Mark medial and lateral mid-axial incisions in continuous
lines along length of arm and forearm
• Place to avoid damage to underlying supercial struc-
tures, including median epicondyle of the elbow (ulnar
nerve), wrist (radial artery), antecubital fossa (brachial
artery, cephalic/basilic/median cubital veins), and
medial bicipital groove (brachial artery). Remain
supercial, only dividing the skin.
2. Perform release along marked incision sites using electrocautery as previously described.
3. Recheck distal perfusion after release.
• Palpation or transcutaneous Doppler assessment of
radial and ulnar arteries or palmar arch
Common Curveballs
Patient with deep circumferential burns of extremities without signs/symptoms of compartment syndrome. The patient
then develops pulselessness of the distal extremity.
Patients with circumferential full-thickness burns of extremi-
ties should be considered for preemptive escharotomies,
as the risk of compartment syndrome may be high in these
patients.
Patient has near-circumferential deep burns to extremities
without signs/symptoms of compartment syndrome.
Patients with deep, near-circumferential burns to extremities
are at high-risk of developing compartment syndrome.
Prophylactic escharotomies are NOT indicated in these
patients. However, they must be closely monitored for the
development of compartment syndrome with frequent
neurovascular checks and/or compartment pressure measurements. Development of compartment syndrome is an
indication of emergent escharotomy in these patients
(Cone and Inaba 2017).
Perfusion not restored after adequate escharotomy.
If distal perfusion remains impaired and/or underlying mus-
cle compartments are bulging or tense after ensuring
adequate escharotomies, proceed with decompressive
fasciotomies.
Fig. 100.1 Leg escharotomy sites, anterior view
Fig. 100.2 Arm escharotomy sites, posterior view
Patient becomes hypotensive.
Deeper burns and inhalation injury sequester more intravas-
cular volume due to inammatory mediators from burn
injury contributing to overall hypovolemic shock.
Consider the need for resuscitation, other traumatic
injury, or abdominal compartment syndrome from
over-resuscitation.
Clean Kills
• Failure to initiate resuscitation when indicated.
332
W. Y. Rockne and T. L. Chin
• Incomplete escharotomy.
• Missing need for fasciotomy after escharotomy.
• Failure to protect underlying neurovascular structures.
Circumferential Burns oftheChest or
Abdomen
Concept
Circumferential burns of the chest may result in respiratory
compromise including increased peak inspiratory pressures,
hypoxia, and hypercapnia as chest wall compliance is compromised by stiff eschar. Circumferential burns of the abdomen can result in abdominal hypertension and abdominal
compartment syndrome, especially when combined with
massive uid resuscitation in large burns. Bladder pressures,
urine output, and peak airway pressures should all be closely
monitored in these patients to allow early detection of
abdominal compartment syndrome.
How Question May BeAsked (Example 1)
“A 33-year-old male presents to the emergency department
after being extricated from a burning car. First responders
report that the patient’s clothes had caught on re, and that
the patient has deep burns to the front, back, and sides of his
torso. The patient was maintaining oxygen saturations initially, but pulse oximetry currently shows an O2 saturation of
89% despite supplemental oxygen and the patient states he
feels like he cannot take deep breaths.”
How toAnswer?
Take a brief history and physical examination while resuscitating the patient.
History
• Mechanism of injury involving burns to the chest, clothing catching on re.
• Asthma, COPD history.
this case can be determined by physical examination
alone.
• Standard labs, ABG, (but do not delay treatment).
• CXR to rule out pneumothorax, hemothorax, rib
fractures.
Treatment
• ABCs
Escharotomy oftheTorso and/or Abdomen
(Gillenwater andGarner 2020) (Fig.100.3)
1. Mark out planned incisions on chest wall and/or
abdomen.
• Incisions should include midaxillary lines, ventral
midline, and subcostal margin.
• Anatomical landmarks for incisions: bilateral midaxillary lines, costal margins inferiorly, midline from sternal notch to subcostal margins.
2. Perform release along marked incision sites using electrocautery as previously described.
• Can use scalpel for sharp release if the patient is with
severe respiratory compromise and performing emergently at bedside
3. Assess adequacy of release.
• Symmetric bilateral excursion of chest wall with
ventilation
• Ventilation without impedance from burn wound
How Question May BeAsked (Example 2)
“A 56-year-old male patient was previously admitted to the
ICU with an 80% TBSA and circumferential full-thickness
burns to his torso. He is currently intubated and sedated. You
are paged that the patient is having high peak inspiratory
pressures and that his urine output has dropped off over the
last few hours.”
Physical Examination
• Circumferential burns to chest, axilla, and back.
• Lack of chest wall movement during inspiration/
exhalation.
• Dyspnea, shortness of breath, sensation of chest
constriction.
• Low oxygen saturation on pulse oximetry, cyanosis.
• High peak inspiratory pressures in intubated patient.
Diagnostic Tests
Can be considered, but do not delay treatment for diagnostic labs, as the need for decompressive escharotomy in
Fig. 100.3 Torso escharotomies incisions
100 Burn Escharotomy
333
How toAnswer?
History
• Large TBSA burn, burn injury to abdomen, clothing
catching on re
• Recent/ongoing large-volume uid resuscitation
Physical Examination
• Circumferential burns to abdomen
• Abdomen tight/tense to palpation
Diagnostic Tests
• Standard labs, ABG
• Bladder pressure (keep in mind, only accurate if patient is
paralyzed)
• Reduced urine output
• Elevated peak airway pressures on ventilator
Treatment
• ABCs
Escharotomy oftheAbdomen (Gillenwater
andGarner 2020)
1. Mark out planned abdominal incisions.
• Incisions should include midaxillary lines, ventral
midline, and subcostal margin.
• Anatomical landmarks for incisions: bilateral midaxillary lines to anterior superior iliac spine, costal margins superiorly, midline from costal margin to pubic
symphysis (see illustration above).
2. Perform release along marked incisions sites using electrocautery as previously described.
• Can use scalpel for sharp release if performing emer-
gently at bedside.
3. Assess adequacy of release.
• Abdomen soft to palpation, free excursion with
respiration.
• Normalization of bladder pressure, peak airway pres-
sures if previously elevated.
• Adequate urine output.
In severe burns and/or burns with large TBSA percentage, mas-
sive uid resuscitation is often required. This can precipitate
the development of extremity or abdominal compartment
syndromes independent of circumferential burns. These
high-risk patients require close monitoring, so that decompressive laparotomy or extremity fasciotomies may be performed in a timely fashion in appropriate cases.
Patient has continued symptoms of abdominal compart-
ment syndrome despite adequate escharotomy.
If a patient continues to have elevated peak airway pressures,
elevated bladder pressures, poor urine output, and a tense/
distended abdomen after adequate escharotomies (including additional relaxing incisions and crosshatching), they
should undergo urgent decompressive laparotomy.
Clean Kills
• Incomplete escharotomy.
• Failure to initiate resuscitation.
• Failure to detect and promptly treat concurrent inhalational injury.
• Failure to detect and treat ongoing abdominal compartment syndrome after escharotomy.
Bonus Points
• Consider additional relaxing incisions or crosshatching of
eschar if initial escharotomy incisions are not sufcient.
• If concerned for compartment syndrome of foot, perform
dorsal release. Toe releases are generally not indicated.
• Pulselessness is one of the latest clinical signs of extremity compartment syndrome, while pain is generally the
earliest. Palpable pulses do not rule out extremity compartment syndrome.
Common Curveballs
After escharotomy, chest wall compliance remains poor and
chest movement is visibly restricted with ventilation.
If standard incisions do not fully decompress chest wall,
additional releasing incisions or crosshatching of the
unreleased eschar may be necessary.
Patients with large TBSA but without circumferential
burns develop signs of extremity or abdominal compartment
syndrome.
Words ofWisdom
Patients with full thickness burns may require escharotomies. We open the eschar to allow for space for swelling
which is inevitable. The escharotomies are ultimately
removed when the burn is excised. Escharotomies are temporary treatments to improve compression on the nerves
which can lead to neurologic compromise, and improve perfusion to the muscles which can become ischemic.
Do not forget to resuscitate the patient and consider other
causes of hypotension in the burn patient. Escharotomies are
rarely emergent after injury. The body will need time to swell
to cause pressure or compression.
334
W. Y. Rockne and T. L. Chin
Bibliography
Cone J, Inaba K. Lower extremity compartment syndrome. Trauma
Surg Acute Care Open. 2017;2:e000094.
Gillenwater J, Garner W. Eschartotomy in burns. In: Atlas of surgical
techniques in trauma. 2nd ed. New York: Cambridge University
Press; 2020. p.439–45.
Zhang L, Labib A, Hughes PG.Escharotomy. In: StatPearls. Treasure
Island: StatPearls Publishing; 2023.
Burn Sepsis
MalloryJebbia andTheresaL.Chin
101
Concept
The majority of questions will be related to management of
sepsis related to wound infections and ventilator-associated
pneumonia.
Way aQuestion May BeAsked
“A 45-year-old man is admitted to the burn intensive care
unit (ICU) for 50% total body surface area (TBSA) burns to
the face, chest, back, and arms after a propane tank explosion. He is intubated and postoperative day 2 from his initial
debridement. He developed fevers to 39.4°C and his white
blood cell count increased from 9 to 15. He becomes tachycardic and hypotensive. How would you manage this
patient?”
Be sure to go through your differential diagnosis (DDx)
for fevers including atelectasis, pneumonia, venous thromboembolism (VTE), urinary tract infection (UTI), wound
infection, or drug-related fevers.
How toAnswer?
History
• Start with ABCs.
• Details of the burn:
– Partial or full thickness, TBSA (larger and deeper
burns have more insensible losses).
– Presence of inhalation injury (from prolonged smoke
inhalation) puts patients at higher risk for ventilatorassociated pneumonia and ARDS.
– History of venous thromboembolism (VTE).
M. Jebbia · T. L. Chin (*)
Division of Trauma, Surgical Critical Care and Burns, UC Irvine,
Orange, CA, USA
e-mail: mjebbia@hs.uci.edu; chintl1@hs.uci.edu
– History of immunosuppression.
– Was there additional trauma—missed injury?
Physical Examination
• Check vital signs: look for fever, tachycardia, and
hypotension.
• Check for swelling in all extremities (differential diagnosis: deep venous thrombosis).
• Check for increasing oxygen requirements or changes in
secretions (hypoxemia may lead to higher consideration
of pneumonia as cause of sepsis).
• Examine wounds and look for signs of infection.
– Rapid change in appearance (loss of previously viable
tissue)
Most reliable sign of burn wound infection is conversion of an area of partial-thickness injury to fullthickness necrosis.
– Discoloration (green drainage may be from
Pseudomonas infection)
– Pain
– Purulence (may not be present in an infected burn
wound)
– Exudate
– Edema/swelling
– Tenderness
– Malodor
– Peri-burn cellulitis
• Urine output as a marker of end-organ perfusion
Diagnostic Tests
• Full laboratory panel including lactate and/or base decit
• Blood/urine cultures (remember: as with any ICU patient,
remove lines when no longer needed)
• Bronchoalveolar lavage or tracheal aspirate for culture
• Chest X-ray
• Wound culture (may need to send deep tissue cultures)
• Venous U/S duplex if concern for DVT
• CT scan to evaluate for intra-abdominal infection (if there
is history of additional trauma)
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_101
335
336
M. Jebbia and T. L. Chin
Treatment
• Fluid resuscitation—30cc/kg bolus (burn patients have
higher insensible losses than other patients).
• Antibiotics (broad spectrum, covering Staph aureus and
Pseudomonas).
• Consider topical antimicrobial therapy.
• Control source—if wound might be the source, debride
and excise necrotic tissue.
• Vasopressors to maintain end-organ perfusion until intravascular volume is restored.
Common Curveballs
Persistent hypotension or fevers after additional excisional
debridement. Check for other sources of shock. Check culture sensitivities to ensure adequate antibiotic coverage. If
hypotension is persistent despite source control and adequate
antibiotic coverage, consider adrenal insufciency. Consider
hemorrhagic shock if there is a traumatic mechanism.
Consider cardiogenic shock if there was blunt force to the
chest or a patient at risk for cardiac events. Consider a pulmonary embolism or obstructive shock.
Alternate Scenario
A 45-year-old male is admitted to the burn ICU with 50%
TBSA to the chest, abdomen, and extremities. He was intubated in the ED and is brought to the burn ICU for resuscitation. Twelve hours after admission, you are called by the
nurse for hypotension. How do you proceed?
Don’t forget burn patients can become hypotensive from
third spacing uids and intravascular hypovolemia (in the
setting of total body hypervolemia) and compartment syndrome, not just infections! This patient has a large burn and
could be experiencing hypotension from loss of intravascular
volume or possibly abdominal compartment syndrome. See
the patient, keep the differential broad, and then narrow it
down. Do a focused exam—check the wounds (it is early in
the hospital course for an infection but should be examined);
look for signs of bleeding; listen to lung sounds to rule out
pneumothorax. Check urine output for evidence of underresuscitation. Check compartments and bladder pressures. If
you are considering compartment syndrome, perform
decompressive laparotomy. If the burn on the abdomen is full
thickness with eschar, sometimes an escharotomy is warranted and will improve the hypotension; however if the
hypotension does not improve, a decompressive laparotomy
should be considered.
• No uid resuscitation
• No debridement of infected wound
• Not performing escharotomies or decompressive laparotomy in cases of abdominal compartment syndrome
• Not considering or diagnosing other causes of shock
Summary
Burn sepsis is a cause of signicant mortality and should
be recognized and managed quickly. Do not forget differentials for fevers and hypotension. Remember wind,
water, walking, wound, and wonder drug. Check for
compartment syndrome. In cases of refractory hypotension without a found source, consider a missed injury
from trauma (e.g., blast injury or associated fall) or adrenal insufciency.
Some facts about burn sepsis:
• Incidence of sepsis in burn patients can range between 3
and 30% for burns more than 20% TBSA.
• Fifty-four percent of burn-related deaths occur due to septic shock.
• The major cause of early burn wound infection is
Staphylococcus aureus.
• On day 5–7 Pseudomonas aeruginosa is the most common cause of burn wound infection.
• Incidence of burn wound sepsis has declined from 6 to
1% since the practice of early burn wound debridement;
however for patients with TBSA >15%, the incidence has
remained the same.
• Highest rate of surgical burn wound infections occurs in
the lower extremities.
• Patients with burn wounds also have high rates of other
types of infection, such as catheter-related infection.
Bibliography
Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS,
Logsetty S.Burn injury. Nat Rev Dis Primers. 2020;6(1):11. https://
doi.org/10.1038/s41572- 020- 0145- 5. PMID: 32054846; PMCID:
PMC7224101.
Stanojcic M, Abdullahi A, Rehou S, Parousis A, Jeschke
MG. Pathophysiological response to burn injury in adults.
Ann Surg. 2018;267(3):576–84. https://doi.org/10.1097/
SLA.0000000000002097. PMID: 29408836; PMCID:
PMC8966302.
Zhang P, Zou B, Liou YC, Huang C.The pathogenesis and diagnosis
of sepsis post burn injury. Burns Trauma. 2021;9:tkaa047. https://
doi.org/10.1093/burnst/tkaa047. PMID: 33654698; PMCID:
PMC7901709.
Clean Kills
• Not getting cultures before starting empiric antibiotics
Cardiac Trauma
EricaRoth andChristinaL.Jacovides
102
Penetrating Cardiac Injury
Concept
The majority of questions will be related to addressing airway, breathing, circulation (ABCs) in the initial trauma
resuscitation and the time-sensitive identication of potential injuries. Maintaining a differential diagnosis of potential
life-threatening injuries and identifying them quickly is
important. Nearly all penetrating chest wound scenarios will
be operative. Recall the indications for an emergency department thoracotomy (EDT) and be able to describe the steps.
Way Question May BeAsked
A 25-year-old man presents to the trauma bay with a gunshot
wound to the chest and unstable vital signs.
How toAnswer?
Initial Evaluation
In all trauma scenarios, start with the primary and secondary
survey, using trauma bay adjuncts as necessary, to quickly
identify life-threatening pathologies, including cardiac tamponade, tension pneumothorax, and hemorrhage. While
some trauma surgeons advocate for rapid exposure and early
roll of penetrating trauma patients to identify external
wounds before proceeding with the ABCs, for the oral
boards, remember that your examiners may not be trauma
E. Roth
Department of Surgery, Temple University Hospital,
Philadelphia, PA, USA
e-mail: erica.roth@emory.edu
C. L. Jacovides (
Division of Trauma, Surgical Critical Care, and Burn Surgery,
Department of Surgery, Temple University Hospital,
Philadelphia, PA, USA
e-mail: christina.jacovides@tuhs.temple.edu
*)
surgeons themselves, so ensure that you adhere to Advanced
Trauma Life Support (ATLS) protocols and the ABCs.
Primary Survey
• Airway
– Assess the airway and prepare to intubate if the patient
is not protecting the airway.
– Avoid intubation if possible as induction may worsen
hemodynamics in a patient in shock.
• Breathing
– Assess for bilateral breath sounds and place the chest
tube if unequal; consider needle decompression prior to
chest tube placement if the patient is unstable. Needle
decompression may not decompress the chest in up to
40% of patients. Consider nger thoracostomy.
• Circulation
– Assess peripheral pulses; establish adequate intrave-
nous (IV) access.
– IV access should be either via two large-bore IVs or
Cordis placement. A triple lumen catheter will not
allow for appropriately rapid administration of blood
products and should not be your initial move for intravenous access.
– Call for blood if there are any signs of hemorrhage.
Have a low threshold to activate a massive transfusion
protocol (MTP).
• Disability
– Assess Glasgow Coma Scale (GCS) score and
disability.
• Exposure
– Examine the patient fully to identify all external signs
of trauma.
– Injuries within the cardiac box (e.g., dened as an area
of the thorax bounded by the clavicles superiorly, the
nipples laterally, and the xiphoid and costal margin
inferiorly) elevate concern for a cardiac injury.
– Note that Beck’s triad for pericardial tamponade (muf-
ed heart sounds, hypotension, and jugular venous distension) is not present in patients with cardiac injuries
up to 25% of the time.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_102
337
338
E. Roth and C. L. Jacovides
Trauma Bay Adjuncts
• Focused Assessment with Sonography for Trauma (FAST)
– A FAST that is positive in the pericardial view is highly
suggestive of cardiac injury and mandates further
intervention.
– A FAST that is negative in the pericardial window does
not completely rule out a cardiac injury, particularly if
there is a concomitant hemothorax since the wound
may violate the pericardium and decompress into
either hemithorax.
– The FAST exam may also be limited by operator expe-
rience or by concomitant hemopneumothorax or subcutaneous emphysema that obscures the views.
• Chest X-ray (CXR)
– CXR may identify hemothorax, pneumothorax, or
enlarged cardiac silhouette.
– In the setting of gunshot wounds, it may also identify
retained missiles that may help to determine the trajectory and associated injuries.
• Chest Computed Tomography (CT)
– Chest CT should rarely if ever be used in a patient with
a signicant clinical concern for penetrating cardiac
injury.
– If the patient is hemodynamically stable and there is a
low clinical suspicion for a hemodynamically signicant cardiac injury, CT can dene missile trajectory
and identify potential injuries.
– Do not perform CT if the patient is hemodynamically
unstable, does not respond to initial resuscitation, or
has a positive pericardial view on FAST exam. Most
likely, it is not the appropriate maneuver in a patient
with a cardiac injury, either on the boards or in real
life.
Secondary Survey
• Once the primary survey and adjuncts are performed, a
rapid but complete head-to-toe assessment of the patient
should be performed to ensure there are no additional
external signs of trauma.
Treatment
Patients with penetrating thoracic trauma and a positive
pericardial FAST should be managed in the operating room.
Patients with a negative pericardial FAST and hemothorax
on CXR likely require additional evaluation to rule out cardiac injury—either a pericardial window or a CT scan.
Patients with a negative pericardial FAST and no hemothorax on CXR may not require operative intervention, although
a CT scan may be performed to clarify the trajectory.
For a penetrating chest wound with a positive pericardial
view on FAST in a hemodynamically stable patient, consider
a pericardial window. There are three options for performing
this:
Subxiphoid Pericardial Window
1. Make a 5–6cm vertical midline incision over the xiphoid
process.
2. Dissect down to xiphoid and resect.
3. Dissect in the retrosternal plane down to the pericardium
and grasp with two Allis clamps.
4. Position the patient in steep reverse Trendelenburg so that
any pericardial uid is in a dependent location at the site
of your incision.
5. Ensure that there is no blood in the operative eld and
make a small cut between the two clamps.
6. If clear or minimal uid is evacuated, the pericardial window is negative. If blood or clot is evacuated, the pericardial window is positive and further intervention is
required.
Transdiaphragmatic Pericardial Window
1. Identify falciform ligament at its diaphragmatic
reection.
2. Use a vertical incision to divide the diaphragm to the left
of the falciform.
3. Dissect down to pericardium and grasp with two Allis
clamps.
4. Position the patient in steep reverse Trendelenburg so that
any pericardial uid is in a dependent location at the site
of your incision.
5. Ensure that there is no blood in the operative eld and
make a small cut between the two clamps.
6. If clear or minimal uid is evacuated, the pericardial window is negative. If blood or clot is evacuated, the pericardial window is positive and further intervention is
required.
Parasternal Pericardial Window
1. Make an incision in the fourth to fth intercostal space
just to the left of the sternum.
2. Dissect down through the intercostal muscles to the
pericardium.
3. Grasp the pericardium with two clamps.
4. Ensure that there is no blood in the operative eld and
make a small cut between the two clamps.
5. If clear or minimal uid is evacuated, the pericardial window is negative. If blood or clot is evacuated, the
pericardial window is positive and further intervention is
required.
If the pericardial window is positive and the patient is
hemodynamically stable or if there is sufcient concern for
cardiac injury that pericardial window is not deemed
necessary:
Median Sternotomy
1. Make a vertical incision from the suprasternal notch to
the xiphoid process (or extend the incision from the incision made for the pericardial window), and dissect down
to the sternum.