Escharotomy | |
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ICD-9-CM | 86.09 |
An escharotomy is a surgical procedure used to treat full-thickness (third-degree) circumferential burns. In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed eschar . Following a full-thickness burn, as the underlying tissues are rehydrated, they become constricted due to the eschar's loss of elasticity, leading to impaired circulation distal to the wound. An escharotomy can be performed as a prophylactic measure as well as to release pressure, facilitate circulation and combat burn-induced compartment syndrome.
An escharotomy is performed by making an incision through the eschar to expose the fatty tissue below. Due to the residual pressure, the incision will often widen substantially.
Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of 30 mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to prevent tissue death. If ischemia (poor blood flow) persists for over six hours, then the irreversible process of muscle necrosis will begin. [1]
The circumferential eschar over the torso can lead to significant compromise of chest wall excursions and can hinder ventilation. Abdominal compartment syndrome with visceral hypoperfusion is associated with severe burns of the abdomen and torso. Due to the primarily diaphragmatic breathing done by children, anterior burns may be enough to warrant an escharotomy. [2] Similarly, airway patency and venous return may be compromised by circumferential burns involving the neck.
Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise.
Indications for emergency escharotomy are the presence of a circumferential eschar with one of the following:
Neurovascular integrity should similarly be monitored frequently and in a scheduled manner. Capillary refilling time, Doppler signals, pulse oximetry, and sensation distal to the burned area should be checked every hour. [4] Limb deep compartment pressures should be checked initially to establish a baseline. Subsequently, any increase in capillary refill time, decrease in Doppler signal, or change in sensation should lead to rechecking the compartment pressures. Compartment pressures greater than 30 mm Hg should be treated by immediate decompression via escharotomy and fasciotomy, if needed. [3]
During an escharotomy the patient is often sedated despite the insensible eschar. The burnt skin is incised down to the subcutaneous fat and into the healthy skin (up to 1 cm). The incisions should be deep enough to release all restrictive effects from the eschar. The operation can be performed on the trunk, limbs, or neck, all while avoiding critical nerves, veins, and vessels. [2] Following the operation the wounds are dressed primarily with an absorbent, antimicrobial material, then wrapped lightly in a bandage. Elevation (if possible) and observation are encouraged. [4]
Compartment syndrome is a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. There are two main types: acute and chronic. Compartments of the leg or arm are most commonly involved.
Skin grafting, a type of graft surgery, involves the transplantation of skin. The transplanted tissue is called a skin graft.
Fasciotomy or fasciectomy is a surgical procedure where the fascia is cut to relieve tension or pressure in order to treat the resulting loss of circulation to an area of tissue or muscle. Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. It is also sometimes used to treat chronic compartment stress syndrome. The procedure has a very high rate of success, with the most common problem being accidental damage to a nearby nerve.
An eschar is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, necrotizing spider bite wounds, tick bites associated with spotted fevers and exposure to cutaneous anthrax. The term ‘eschar’ is not interchangeable with ‘scab’. An eschar contains necrotic tissue whereas a scab is composed of dried blood and exudate.
Mastopexy is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. In a breast-lift surgery to re-establish an aesthetically proportionate bust for the woman, the critical corrective consideration is the tissue viability of the nipple-areola complex (NAC), to ensure the functional sensitivity of the breasts for lactation and breast-feeding.
Cutis marmorata telangiectatica congenita is a rare congenital vascular disorder that usually manifests in affecting the blood vessels of the skin. The condition was first recognised and described in 1922 by Cato van Lohuizen, a Dutch pediatrician whose name was later adopted in the other common name used to describe the condition – Van Lohuizen Syndrome. CMTC is also used synonymously with congenital generalized phlebectasia, nevus vascularis reticularis, congenital phlebectasia, livedo telangiectatica, congenital livedo reticularis and Van Lohuizen syndrome.
Capillary leak syndrome, or vascular leak syndrome, is characterized by the escape of blood plasma through capillary walls, from the blood circulatory system to surrounding tissues, muscle compartments, organs or body cavities. It is a phenomenon most commonly witnessed in sepsis, and less frequently in autoimmune diseases, differentiation syndrome, engraftment syndrome, hemophagocytic lymphohistiocytosis, the ovarian hyperstimulation syndrome, viral hemorrhagic fevers, and snakebite and ricin poisoning. Pharmaceuticals, including the chemotherapy medications gemcitabine and denileukin diftitox, as well as certain interleukins and monoclonal antibodies, can also cause capillary leaks. These conditions and factors are sources of secondary capillary leak syndrome.
Replantation or reattachment has been defined by the American Academy of Orthopaedic Surgeons as "the surgical reattachment of a body part that has been completely cut from the body".
The fascial compartments of the leg are the four fascial compartments that separate and contain the muscles of the lower leg. The compartments are divided by septa formed from the fascia. The compartments usually have nerve and blood supplies separate from their neighbours. All of the muscles within a compartment will generally be supplied by the same nerve.
A neurovascular bundle is a structure that binds nerves and veins with connective tissue so that they travel in tandem through the body.
Emergency bleeding control describes actions that control bleeding from a patient who has suffered a traumatic injury or who has a medical condition that has caused bleeding. Many bleeding control techniques are taught as part of first aid throughout the world, though some more advanced techniques such as tourniquets, are often taught as being reserved for use by health professionals, or as an absolute last resort, to mitigate associated risks, such as potential loss of limbs. To manage bleeding effectively, it is important to be able to readily identify types of wounds and types of bleeding.
A compartment syndrome is an increased pressure within a muscular compartment that compromises the circulation to the muscles.
Skin biopsy is a biopsy technique in which a skin lesion is removed to be sent to a pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician's office, and results are often available in 4 to 10 days. It is commonly performed by dermatologists. Skin biopsies are also done by family physicians, internists, surgeons, and other specialties. However, performed incorrectly, and without appropriate clinical information, a pathologist's interpretation of a skin biopsy can be severely limited, and therefore doctors and patients may forgo traditional biopsy techniques and instead choose Mohs surgery. There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy. The choice of the different skin biopsies is dependent on the suspected diagnosis of the skin lesion. Like most biopsies, patient consent and anesthesia are prerequisites.
A supracondylar humerus fracture is a fracture of the distal humerus just above the elbow joint. The fracture is usually transverse or oblique and above the medial and lateral condyles and epicondyles. This fracture pattern is relatively rare in adults, but is the most common type of elbow fracture in children. In children, many of these fractures are non-displaced and can be treated with casting. Some are angulated or displaced and are best treated with surgery. In children, most of these fractures can be treated effectively with expectation for full recovery. Some of these injuries can be complicated by poor healing or by associated blood vessel or nerve injuries with serious complications.
Artificial skin is a collagen scaffold that induces regeneration of skin in mammals such as humans. The term was used in the late 1970s and early 1980s to describe a new treatment for massive burns. It was later discovered that treatment of deep skin wounds in adult animals and humans with this scaffold induces regeneration of the dermis. It has been developed commercially under the name Integra and is used in massively burned patients, during plastic surgery of the skin, and in treatment of chronic skin wounds.
Abdominal compartment syndrome (ACS) occurs when the abdomen becomes subject to increased pressure reaching past the point of intra-abdominal hypertension (IAH). ACS is present when intra-abdominal pressure rises and is sustained at > 20 mmHg and there is new organ dysfunction or failure. ACS is classified into three groups: Primary, secondary and recurrent ACS. It is not a disease and as such it occurs in conjunction with many disease processes, either due to the primary illness or in association with treatment interventions. Specific cause of abdominal compartment syndrome is not known, although some causes can be sepsis and severe abdominal trauma. Increasing pressure reduces blood flow to abdominal organs and impairs pulmonary, cardiovascular, renal, and gastro-intestinal (GI) function, causing obstructive shock, multiple organ dysfunction syndrome and death.
Arterial insufficiency ulcers are mostly located on the lateral surface of the ankle or the distal digits. They are commonly caused by peripheral artery disease (PAD).
Surgical positioning is the practice of placing a patient in a particular physical position during surgery. The goal in selecting and adjusting a particular surgical position is to maintain the patient's safety while allowing access to the surgical site. Often a patient must be placed in an unnatural position to gain access to the surgical site.
Scalp reconstruction is a surgical procedure for people with scalp defects. Scalp defects may be partial or full thickness and can be congenital or acquired. Because not all layers of the scalp are elastic and the scalp has a convex shape, the use of primary closure is limited. Sometimes the easiest way of closing the wound may not be the ideal or best way. The choice for a reconstruction depends on multiple factors, such as the defect itself, the patient characteristics and surgeon preference.
Diffuse capillary malformation with overgrowth (DCMO) is a subset of capillary malformations (CM) associated with hypertrophy, i.e. increased size of body structures. CM can be considered an umbrella term for various vascular anomalies caused by increased diameter or number of capillary blood vessels. It is commonly referred to as "port-wine stain", and is thought to affect approximately 0.5% of the population. Typically capillaries in the papillary dermis are involved, and this gives rise to pink or violaceous colored lesions. The majority of DCMO lesions are diffuse, reticulated pale-colored stains.