Fasciotomy for Compartment Syndrome

[DeadCactus]

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Barring the extreme situations, is this an EM procedure? I see it listed in texts and described in EM procedure books but is it actually done outside of remote settings?

 

[EctopicFetus]

no..

 

[Birdstrike]

For the purposes of the ABEM cert and recert exams, it is. I've not worked at a burn center, so out of 30,000 + patient encounters, I've never done one. I can't see it being too hard to cut cooked skin, if I needed to do a chest wall fasciotomy to be able to ventilate someone.

 

[turkeyjerky]

For the purposes of the ABEM cert and recert exams, it is. I've not worked at a burn center, so out of 30,000 + patient encounters, I've never done one. I can't see it being too hard to cut cooked skin, if I needed to do a chest wall fasciotomy to be able to ventilate someone.

You're describing an escharatomy, big difference from a fasciotomy. The former is in our scope of practice, the later is not.

 

[Groove]

http://emedicine.medscape.com/article/2058838-overview

Fasciotomy is within our scope of practice in the sense that it's on exams and in our literature, but I honestly doubt that I have hospital privileges to perform one though I'd have to check. Regardless, I saw one done in residency in the ED but it was by the surgeons. If I had a pt that needed an emergent one done in the ED prior to transfer, I'd probably call the surgeon in though I've yet to find myself in that situation yet. Could I wing it? Probably (with much googling and reference diagrams). Would it be best for the pt? Probably not.

 

[Birdstrike]

You're describing an escharatomy, big difference from a fasciotomy. The former is in our scope of practice, the later is not.

Duh...you're right. I have board review on the brain. He wrote fasciotomy, I saw escharotomy. My bad. Hopefully I won't have that brain fart on the boards. Lol. Thanks.

Not only has board review made my brain equate escharotomy with fasciotomy, it's filled my head with other nonsense like, "Kids are not little people," when in fact they are little. And also people.

Yes, don't cut people's fascial compartments in the ED, okay.

 

[Arcan57]

Even cooked skin bleeds a fair amount. If you need to do an escharotomy, grabbing the bovie can make life significantly better.

 

[deleted547339]

.

 

[dchristismi]

...cause, you know, that's a piece of equipment I use all the time, and have lying around my ED. 😉

(Sorry. Feeling sarcastic this morning. Apparently need more coffee...)
Yes, it's a good thought, but it would not occur to me in the heat of the moment. I think I'd be more concerned getting a damn helicopter inbound.
And I have done neither procedure, nor do I ever hope to.

 

[Apollyon]

...cause, you know, that's a piece of equipment I use all the time, and have lying around my ED. 😉

(Sorry. Feeling sarcastic this morning. Apparently need more coffee...)
Yes, it's a good thought, but it would not occur to me in the heat of the moment. I think I'd be more concerned getting a damn helicopter inbound.
And I have done neither procedure, nor do I ever hope to.

You don't have those disposable 5000 degree or whatever cautery things, which are great for drilling the holes in the nails for the subungal hematomata?

 

[Modafinil]

You don't have those disposable 5000 degree or whatever cautery things, which are great for drilling the holes in the nails for the subungal hematomata?

The glowing tip has a great habit of freaking patients out

 

[Apollyon]

The glowing tip has a great habit of freaking patients out

Well, at least, if using for escharotomy, the smell of burned flesh overwhelms the smell of...burned flesh. And, as @Arcan57 rightly states, it's like a hot knife through butter.

Butter, I tells ya! Butter!

 

[Apollyon]

I just did cursory Google-fu research, and found that one maker of such electrocautery pens has them from 1500 to 2200 degrees F.

 

[deleted547339]

The glowing tip has a great habit of freaking patients out

Seen this done several times in our ED (we see a ton of burns)....patients usually aren't freaked out because they have a plastic tube down their throat.

Side question: what do you use for sedation in trauma/burn patients?

 

[Modafinil]

Seen this done several times in our ED (we see a ton of burns)....patients usually aren't freaked out because they have a plastic tube down their throat.

Side question: what do you use for sedation in trauma/burn patients?

Hah I was talking about popping through fingernails. The burn guys are out like lights.

Pretty soon it's going to be propofol. Right now it's most often versed/fentanyl.

 

[Arcan57]

...cause, you know, that's a piece of equipment I use all the time, and have lying around my ED. 😉

(Sorry. Feeling sarcastic this morning. Apparently need more coffee...)
Yes, it's a good thought, but it would not occur to me in the heat of the moment. I think I'd be more concerned getting a damn helicopter inbound.
And I have done neither procedure, nor do I ever hope to.

I didn't think of it either the first time I did one. Scalpel worked really well for cutting through but despite 99% 3rd degree burns he still bled like crazy from the incisions. Guy next to him got bovied and was hemostatic throughout. Can't really say either ultimately benefited though.

I use propofol but would be open to ketamine.

 

[Rendar5]

Propofol and fentanyl as combo drip. It hurts like hell even if you are unconscious. Let's you use less propofol too