Case: 57 yo M who presents via EMS found with circumferential burns on bilateral lower extremities, left upper extremity, lower pelvis, and left side of chest after being trapped in a burning tent. Unknown time of incident.

VS: HR: 128, RR: 24, BP: 112/64, SpO2 96% on 4L O2

Alert, oriented x 2. SEVERELY DISTRESSED. Singed nares bilaterally. Bilateral wheezes, tachypneic. Tachycardic, RR. Abd S/NT/ND. Once again, 3rd degree burns circumferential burns from lower pelvis, extending to groin, and down to bilateral lower extremities. The 3rd degree burn covered the left side of his chest and his RUE. No pulses were palpated in his LUE or BLE. Though burned, BLE and RUE appeared blanched with poor cap refill and cool to touch. 72% estimated burn coverage total. Pt stated he was unable to feel or move bilateral lower extremities.

During the process of IV, O2, monitor, and moving the pt over. I called for pain medication, intubation meds, and got the equipment ready for intubation.

Trauma, Plastics, Urology – paged. Don’t wait to get consults on board in a case where you are preparing to do this procedure.

On physical exam, remember Wallace rule of nines (see total body surface area): 9% for each arm, 18% for each leg, 18% for the front of the torso, 18% for the back of the torso, and 9% for the head and 1% for the perineum. At the same time, think Lactated Ringers at 4 mL x kg x percentage burn = total fluids needed for replacement in initial 24hrs. First half of amount in first 8 hours with the second half over 16hrs{{Parkland}}.

But, first, intubate to secure the airway, provide pain control, and facilitate further exam. Needless to say, burns are extremely painful.. . so are escharotomies.

Trauma wedge took the RLE, and I had the LLE. In the race to get pulses back, I succeeded and was rewarded with getting to do the LUE as well.

How did I perform the procedure you ask? Well, it was with the Trauma fellow standing at the foot of the bed giving instructions and guidance . .. I had never seen anything like this except for textbook cases of a circumferential burn to the chest/trunk. This procedure is not on our sign off list, required list, or on anything that I had seen in cadaver lab.

While these procedures are as rare as a Trauma fellow eager to teach at 2 am, you may be faced with the same in a rural ED or with a wedge stuck in the OR, etc.

Advice: Be nice to your colleagues. And, more importantly, prepare.

Here are some very informative links that would’ve been great to have seen or reviewed prior.

Step 1: Read the Overview

Video 1: Robot voice explanation: Best display of lines for incision, but more from a surgical perspective

Video 2: Australian Escharotomy How-to

FYI:

Suprapubic catheter was also placed in the ED prior to the pt going to the OR. Another rare procedure, not required, but useful to know.