Circumferential Burn

Check Neuromuscular Observations in Distal Extremities: 

• 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 (the average transfer time for severe burn patients is 3.6 hours), the need for escharotomy is uncommon. 

Check for Breathing Difficulties, Chest and Abdomen:

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

Elevate affected areas if appropriate in two steps:

• Sit the patient up if appropriate 
• Elevate Affected Limbs 

This will help to reduce oedema and buy some time. 

Consider escharotomy

Escharotomy may be 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.