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 Table of Contents  
CASE SERIES
Year : 2018  |  Volume : 26  |  Issue : 1  |  Page : 99-102

Decompression escharotomies of burns in children between the ages 0 and 18 years


1 Department of Pediatric Burns and Reconstructive Surgery, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
2 Department of PICU, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
3 Department of Pediatrics, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India

Date of Web Publication11-Mar-2019

Correspondence Address:
Dr. K Mathangi Ramakrishnan
Department of Pediatric Burns and Reconstructive Surgery, Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_7_18

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  Abstract 


Full thickness burns in children often leads to eschar formation which requires escharotomy. Escarotomies in children pose various challenges depending on the site involved, age of the child, mechanism of injury etc. In this article we discuss a series of children under special circumstances who required escharotomies. We are describing the methodology used and precautions to be taken before and after surgical procedure to improve the outcome in these children.

Keywords: Burns infections, childhood burns, escharotomies of burns


How to cite this article:
Ramakrishnan K M, Ramachandran B, Ravi R, Mathivanan T, Ravikumar K G, Jayaraman V. Decompression escharotomies of burns in children between the ages 0 and 18 years. Indian J Burns 2018;26:99-102

How to cite this URL:
Ramakrishnan K M, Ramachandran B, Ravi R, Mathivanan T, Ravikumar K G, Jayaraman V. Decompression escharotomies of burns in children between the ages 0 and 18 years. Indian J Burns [serial online] 2018 [cited 2019 Jul 19];26:99-102. Available from: http://www.ijburns.com/text.asp?2018/26/1/99/253859




  Introduction Top


Full-thickness burns involving epidermis and dermis often result in the formation of eschar in children. Eschar formation results in loss of skin elasticity, which can then lead to edema and compartment syndrome, with risk of loss of limbs and digits. Circumferential eschar in the chest or abdomen may lead to respiratory compromise.

Escharotomy is a very important emergency procedure for both adults and children in burns. This is done to bring back good blood supply to the site which suffers from anoxia. It could occur in the limbs, thorax or abdomen. Escharotomy is indicated when circulation is compromised due to increased pressure in the limb which cannot be relieved by simple elevation.[1]

Indications for escharotomy

Elevation of the affected limb should always be done first and then closely monitored. Signs in a limb that may indicate the need for an escharotomy are as follows: (1) loss of circulation: pallor, cyanosed, and reduced or absent capillary return, (2) coolness, (3) loss of palpable pulses (late sign), (4) decrease pulse pressures as measured using Doppler ultrasound, (5) numbness, and (6) decreased oxygen saturation as detected by using pulse oximetry. In the chest and abdomen, escharotomy should be considered, if there is a respiratory compromise due to poor chest expansion or diaphragmatic movement.

The general condition of the patient must be taken into consideration and procedure withheld in very sick patients in whom the prognosis is poor due to systemic complications. If multiple escharotomies are required, this should be prioritized by the surgeon according to the severity and site of the eschar.


  Methodology Top


The principles of escharotomy are similar in various age groups in children. General anesthesia (GA) is preferable while doing an escharotomy. The extent of blood loss should be assessed and if severe blood transfusion may be required. The use of diathermy at incision site may minimize blood loss. Incisions should be performed longitudinally in the axial line except in chest and abdomen where the transverse elliptical incision is required. Limb circulation and chest expansion should be continually assessed during the procedure.

In some patients, multiple escharotomies are required at the same point of time to get the desired result. It is best to avoid incisions across the flexural creases of joints. In case the eschar crosses a joint, decision has to be taken whether to skip the joint or to crossover it. Single incision of the eschar is sufficient in many cases, but some need excision of the eschar.[2] Full-thickness incision into subcutaneous fat sufficiently to see obvious separation of the wound edges is recommended, although skin-deep incision will suffice in some. The final aim is to ensure distal circulation as assessed by the return of perfusion and peripheral pulses. In case of chest, improvement in ventilator parameters and chest expansion should be the aim.

Preferred cover that we use in the raw area after the return of blood supply is autografts, donor skin, or collagen membrane. Hemostasis and return of circulation are assessed once more, and the resultant raw area is covered with split-skin graft (SSG). Cosmetic corrections have to be done later.

Intravenous (IV) antibiotics are almost always required to cover both Gram-positive and Gram-negative infections according to local microbiological data and sensitivities. The child may need a period of observation in the Intensive Care Unit for management of fluid status and monitoring.

Case series: Escharotomy in special situations

Here, we present six cases where eschar presented with different problems and an account of management in these situations.

Infants with eschar

Infants with eschar in limbs have increased the risk of compartment syndrome and vascular compromise due to the small circumference.[3] An eschar in the abdomen may cause more respiratory embarrassment than in an older child because infants predominantly use diaphragm for breathing, and breathing is mainly abdominal.

[Figure 1] shows hot water burn in a child of 2 years old: Simple escharotomy on the sides of constriction relieved the situation. The postescharotomy status should be monitored for the return of pulses and capillary refill time.
Figure 1: Hot-water burn in a child of 2 years old

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Escharotomy in electrical burns

[Figure 2] shows high-tension electrical burn in a child of 5 years old: Liberal escharotomy under GA, relieved the eschar and the veins got filled with blood. We were able to save the forearm up to the hand.
Figure 2: High-tension electrical burn in a child of 5 years old

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Escharotomy in necrotic eschar

[Figure 3] shows septic burn in a 5-year-old child, with extensive infected eschar. Necrotic ulcer in avascular lower 1/3 of left leg producing constriction. Escharotomy incision cannot be made through the necrotic-infected areas – an ulcer in this case. Escharotomy was done outside the ulcer to relieve tension.
Figure 3: Septic burn in a 5-year-old child, with extensive infected eschar

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Infected burns are not a contraindication for escharotomy. We excise all the dead tissues and cover with biologic dressing-collagens or SSG from a skin bank. When the general condition improves, autografting is done.

In all cases of infected necrotic eschar, appropriate IV antibiotics should be given. In many instances, organisms such as Pseudomonas, Acinetobacter, and Burkholderia cause severe wound infection and sepsis in these children. Antibiotics such as meropenem, amikacin, and colistin may be required at high doses. Children at this stage need to be treated in dedicated pediatric Intensive Care Unit facility with access to mechanical ventilators, high-frequency oscillatory ventilation, and renal replacement therapy. Caution should be exercised while doing surgical procedure in children with overwhelming sepsis, as there is a risk of high mortality.

The constricting tissue is always the avascular anoxic skin in an infected eschar. In some patients, we may have to do multiple escharotomies at the same point of time to get the desired result. In this patient, escharotomy was done in the anterior chest wall. However, the child died due to Acinetobacter infection.

[Figure 4] shows a 13-year-old girl with 36% deep flame burns of the trunk and abdomen. Escharotomy was done; however, the child did not improve and she died of sepsis.
Figure 4: A 13-year-old girl child with 36% deep flame burns of the trunk and abdomen

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Eschar due to electrical burn

[Figure 5] shows constricted eschar of the chest and abdomen in an 18-year-old teenage boy due to the high-tension electrical accident. The boy survived after multiple liberal escharotomies during which eschars were excised totally. The wound was covered with collagen membrane initially, and auto skin grafting was done later.
Figure 5: Constricted eschar of the chest and abdomen in an 18-year-old teenage boy due to high-tension electrical accident

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Extensive deep burns

[Figure 6] shows 75% deep burns of the entire trunk of a 7-year-old girl. Escharotomies did not improve the general condition. The patient died within 72 h due to circulatory failure. Children with extensive and deep burns have decreased intravascular volume and shock. This subsequently leads to multiorgan dysfunction and death.
Figure 6: 75% deep burns of the entire trunk of a 7-year-old girl

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Use of collagen dressing in septic burns

[Figure 7] shows a 4-year-old girl who had third-degree burns of the whole thighs and upper part of the leg with intense wound sepsis. This child was managed as follows:
Figure 7: A 4-year-old girl had third-degree burns of the whole thighs and upper part of the leg with intense wound sepsis

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  • The constricted area was liberally released by vertical incision to release, almost like escharotomy
  • The burn was infected with Pseudomonas and Acinetobacter. After supportive therapy, the tight infected area in the mid-thigh was escharotomized. Systemic antibiotics were given, and the wound was covered with collagen dressing. When the wound became healthy by the 13th day, SSG was applied to cover the area
  • This procedure for the septic eschar of third-degree burns was to have made, resulted in tightening of the limb and gradual healing of the wound. This certainly was a good attempt leading to successful outcome
  • Vascular thrombus formation can be a complication which should be monitored.


Monitoring of postescharotomy status

  1. The surgeon must be satisfied with vascular flow, beyond the constriction
  2. Color of the distal area beyond escharotomy must almost be the same as the proximal skin
  3. Color of the medium-sized blood vessels should be monitored after procedures. Initially, it may be normal color but later may turn blue. This occurrence must be identified soon, and a relook of the escharotomy site and washing of the area may be done. Heparinization used to be performed with low-molecular-weight heparin; however, now, discontinued due to occasional bleeding complications
  4. If the ischemia of the limb is severe and amputation considered, another surgeon must also be involved in the decision, and proper postoperation physiotherapy must be given.



  Conclusion Top


The mechanism of constriction produced by eschar varies in different parts of the body; however, the pathology of eschar is the same in all age groups. Escharotomy must be well planned and performed. Secondary procedures such as attending to the avascular, devitalized area differ in different patients and must be individualized. Coverage with SSG must be performed as soon as possible. Major reconstructions including microsurgery are possible but may have to be done later.

Major reconstructions can be done only if the hemostasis is secured. When large areas of the trunk are involved, they must be covered with bulky dressings applied over the area. This should also exert mild pressure. Dressings are changed after 48 h.

Main principle is to replace the area affected with SSG, wherever available and as soon as possible.

With multiple procedures, long-term results may not be satisfactory and cosmetic corrections may have to be done later.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Australian and New Zealand Burn Association. Emergency Management for Severe Burn Injuries Manual. 15th ed. Australian: New Zealand Burn Association; 2011.  Back to cited text no. 1
    
2.
Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. J Burn Care Res 2009;30:759-68.  Back to cited text no. 2
    
3.
Feldmann ME, Evans J, Seung-Jun O. Early management of the burned pediatric hand. J Craniofac Surg 2008;19:942-50.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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