Has anyone here performed and in field eschorotomy??

justin1232

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I was reading around on rural services having echorotomies working there scope of practice for severe burn injuries. Has anyone ever performed one in field? And if so, what was the point at which the decision was made to perform it?
 

DesertMedic66

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Just before I got into the HEMS world I had a severely burned patient from a TC. 90% 3rd degree burns.

The local HEMS crew that responded ended up doing a surgical cric and an escharotomy. Patient ended up dying a day later at the burn center.

The decision was made after securing the airway and having high airway pressures due to the chest burns.
 

Summit

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I would happily go through my life not having to do that. I hate bad burns. Burn ICU RNs are special awesome people with fascinating and challenging sick patients.
 

CANMAN

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Just before I got into the HEMS world I had a severely burned patient from a TC. 90% 3rd degree burns.

The local HEMS crew that responded ended up doing a surgical cric and an escharotomy. Patient ended up dying a day later at the burn center.

The decision was made after securing the airway and having high airway pressures due to the chest burns.
I have done 1 as a HEMS provider with my previous program, and this was the exact scenario. Scene call at a farm, using gas to start a bonfire.
Was standing order in our protocols. Typically the high PIP's on the vent, or even inability to move the chest with BVM ventilations and circumferential chest burns will be your indications prior to placement on the vent. Works well and you see immediate results if it's indicated and performed, but as Desert said patient prognosis at that point is likely very poor.

At my current program we are the tertiary burn center for the metro area. Don't see it all that often, but when we do it's performed in conjunction with other escharotomies and/or fasciotomies with Bovie cautery. Different Burn Attendings prefer different methods, some will do an H pattern and extend the sides down, mine was performed as a rectangle box pattern.
 

johnrsemt

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King County EMS has them in protocols with relative short transport times?

We have up to 4 hour transport times, and I would love to hear what an ED doctor would say on the phone or radio link if we called for orders for it. Half the time I work we can't get a helicopter due to wind problems
 

TransportJockey

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When I worked in deep west Texas it was the only skill we actually had to call for orders prior to doing. And it’s the one skill I have only ever practiced on cadavers.
 

CANMAN

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King County EMS has them in protocols with relative short transport times?

We have up to 4 hour transport times, and I would love to hear what an ED doctor would say on the phone or radio link if we called for orders for it. Half the time I work we can't get a helicopter due to wind problems
Well based on your consult they're either going to say "go ahead" and the patient might make the transport, or they're going to say no and the patient dies. Those are the two scenarios. When a patient truly needs a chest escharotomy if they don't get one you will not be able to ventilate them and you will get the accompanying sequela of that.
 

PotatoMedic

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I do 2-3 a week, while walking on water and then I put them in a BLS ambulance so I can go back to my Netflix.
I wouldn't put I past "Turfing Tony"... I got some sick patients from him back in my trimed days.

Kcm1 does cover rural areas so they can have decent transport times where that procedure would be useful.
 

KingCountyMedic

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I wouldn't put I past "Turfing Tony"... I got some sick patients from him back in my trimed days.

Kcm1 does cover rural areas so they can have decent transport times where that procedure would be useful.
LOL!

I’ve been involved with one in my 20 years or so. It worked well, patient still didn’t do well in the end. We do one or two a year probably. We do have some rural locations and now we have Vashon Island...

It’s never a good thing when you’re pulling that procedure out of your tool box. Those calls can really haunt ya.
 

Remi

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Is this really ever necessary prehospital? This is usually done a day or so after the burn happens in the ICU or the OR of a burn center. Eschar takes some time to form and firm up, and even then doesn't cause restriction until the underlying tissues start to swell. Considering the risk of bleeding and all the other bad things that can potentially happen when a non-surgeon starts slicing away at someone's torso with a scalpel, I have to wonder if this is really an appropriate thing to ever include in EMS protocols.

At one point it was in the protocols of the second HEMS program that I flew with, but we took it out (along with a few other things) when we realized that we had no way to train the skill and also that it had never been performed. My last program actually flew under contract for a major burn center, and in my few years there I flew quite a few really bad, fresh burns some pretty long distance both by RW and FW. Didn't have escharotomy in my protocols and can't say it ever occurred to me to even consider it.
 

GMCmedic

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Is this really ever necessary prehospital? This is usually done a day or so after the burn happens in the ICU or the OR of a burn center. Eschar takes some time to form and firm up, and even then doesn't cause restriction until the underlying tissues start to swell. Considering the risk of bleeding and all the other bad things that can potentially happen when a non-surgeon starts slicing away at someone's torso with a scalpel, I have to wonder if this is really an appropriate thing to ever include in EMS protocols.

At one point it was in the protocols of the second HEMS program that I flew with, but we took it out (along with a few other things) when we realized that we had no way to train the skill and also that it had never been performed. My last program actually flew under contract for a major burn center, and in my few years there I flew quite a few really bad, fresh burns some pretty long distance both by RW and FW. Didn't have escharotomy in my protocols and can't say it ever occurred to me to even consider it.
IMHO, Escarotomy is one of those "nice to have 1 time in 10 years" type procedures. Typically, those procedures, piece of equipment, medication, etc, aren't worth worrying about.
 

johnrsemt

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I have had to call Medical Control for suggestions for a 750 lb patient who was status epilectus (sp?) who I couldn't get a line in and IM Valium hadn't done much for. And we still had 45 miles to go
I told the doctor that I had tried to drill him, but even with the big needle it barely hit the bone; so he told me to do a cut down, then drill him with a regular needle. So that was fun; He did a quick explanation, then we drove into a dead spot. Got the IO, good line, stopped the seizures; got the doctors name at the beginning, cause by the time I got to the hospital he had gone home.
Attending on the next shift told me that they didn't have a doctor working there by that name: So I was screwed. Good thing he couldn't keep a straight face cause he had me worried for a minute.
 

justin1232

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I have had to call Medical Control for suggestions for a 750 lb patient who was status epilectus (sp?) who I couldn't get a line in and IM Valium hadn't done much for. And we still had 45 miles to go
I told the doctor that I had tried to drill him, but even with the big needle it barely hit the bone; so he told me to do a cut down, then drill him with a regular needle. So that was fun; He did a quick explanation, then we drove into a dead spot. Got the IO, good line, stopped the seizures; got the doctors name at the beginning, cause by the time I got to the hospital he had gone home.
Attending on the next shift told me that they didn't have a doctor working there by that name: So I was screwed. Good thing he couldn't keep a straight face cause he had me worried for a minute.
Hahaha 😂 interesting. Did you cut down just to the fascia?
 

CANMAN

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Is this really ever necessary prehospital? This is usually done a day or so after the burn happens in the ICU or the OR of a burn center. Eschar takes some time to form and firm up, and even then doesn't cause restriction until the underlying tissues start to swell. Considering the risk of bleeding and all the other bad things that can potentially happen when a non-surgeon starts slicing away at someone's torso with a scalpel, I have to wonder if this is really an appropriate thing to ever include in EMS protocols.

At one point it was in the protocols of the second HEMS program that I flew with, but we took it out (along with a few other things) when we realized that we had no way to train the skill and also that it had never been performed. My last program actually flew under contract for a major burn center, and in my few years there I flew quite a few really bad, fresh burns some pretty long distance both by RW and FW. Didn't have escharotomy in my protocols and can't say it ever occurred to me to even consider it.
Although not common in the least bit there are certainly some circumferential chest burns that require/get escharotomies in the trauma bay. I have seen two working clinical in our trauma/burn bays in the last 16 months. True full thickness burned skin becomes extremely tight and the inability to effectively ventilate these people isn't something that only occurs after swelling takes places a day or so later. When this type of skin is cut with a scapel it filets open with minimal effort, much like slicing into a microwaved hotdog. Having done one and witnessed others the bleeding is minimal to none, and there is a dramatic difference in the PIP's and ease of ability to ventilate.

Is it something that alot of systems will ever need, likely not. But, it's not a difficult skill to train on and maintain if you have some exposure and/or are affiliated with a burn center. We train on pigs feet and it's pretty realistic, just cutting a smaller box. IMO if you're trained, it's indicated, and also going to be in the course of the patient's initial hospital management anyway I don't see the hesitation.

Although a low frequency event, the same could be said about needing a surgical airway protocol/ability to perform with bougies and all sorts of rescue airways on the market.
 

KingCountyMedic

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Although not common in the least bit there are certainly some circumferential chest burns that require/get escharotomies in the trauma bay. I have seen two working clinical in our trauma/burn bays in the last 16 months. True full thickness burned skin becomes extremely tight and the inability to effectively ventilate these people isn't something that only occurs after swelling takes places a day or so later. When this type of skin is cut with a scapel it filets open with minimal effort, much like slicing into a microwaved hotdog. Having done one and witnessed others the bleeding is minimal to none, and there is a dramatic difference in the PIP's and ease of ability to ventilate.

Is it something that alot of systems will ever need, likely not. But, it's not a difficult skill to train on and maintain if you have some exposure and/or are affiliated with a burn center. We train on pigs feet and it's pretty realistic, just cutting a smaller box. IMO if you're trained, it's indicated, and also going to be in the course of the patient's initial hospital management anyway I don't see the hesitation.

Although a low frequency event, the same could be said about needing a surgical airway protocol/ability to perform with bougies and all sorts of rescue airways on the market.
Absolutely, well said.

This is why we train. These cases are rare indeed but when you get one and you are a ways out they need to be treated. We train on all of these procedures under the watchful eyes of our Trauma Doctors. Many of these folks will need full court press including surgical airways and central lines. I’m grateful to work in a system where my physicians support me and have given me the training and tools necessary to take care of sick people. If I never see another burn patient for the rest of my career I’ll be happy!
 
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