Out-of-Hospital Chest Escharotomy: A Case Series and Procedure Review

Looking back to inform the future: a review of published paramedicine research

OBJECTIVE

Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community.

METHODS

We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample.

RESULTS

The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice.

CONCLUSIONS

Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.

Surgical Escharotomy and Decompressive Therapies in Burns

Early recognition of the need for escharotomy and other decompressive therapies is imperative for experienced burn providers, as to avoid reversible tissue ischemia and necrosis. With full-thickness burns, the eschar that develops is largely noncompliant. The predictable edema that develops during resuscitation of larger burns increases the likelihood ischemia-inducing pressure, as the underlying tissues swell within noncompliant skin, resulting in burn-induced compartment syndrome. Conventionally, this has been treated with decompressive therapies, such as escharotomy. The most recent surveys have identified that the United States and Canada both face a shortage of practicing burn surgeons. In the event of a burn disaster, many nonburn surgeons would need to provide burn care, including decompressive therapies. We reviewed the literature to provide accurate, accessible, and applicable recommendations regarding this practice following burn injury for both the practicing burn surgeon and those that would provide care in the burn disaster.

Revisiting Escharotomy in Patients With Burns in Extremities

Escharotomy incisions must be made in the inelastic skin eschar that is typical of circumferential third-degree burns. Later, the necrotic tissue must be debrided and substituted with a skin graft. Many reports on this topic have revealed that concepts and techniques vary widely. This study aims to present a critical review of the literature about escharotomy in burns and to highlight a different strategy to perform escharotomy in patients with burned extremities. We conducted a critical review in Pubmed/MEDLINE using the keywords "escharotomy" and "burns." In the present study, we included 22 articles published from 1955 to 2015 (60 years) that contain the aforementioned keywords. With respect to the extremities, most of the publications recommend that medial and lateral longitudinal incisions be performed and that care must be taken to avoid deep structures, particularly nerves. Moreover, the publications mention that escharotomy might result in thick, hypertrophic, retracting, and painful scars. We advocate that incisions performed only on the lateral and medial borders of the extremities are usually unnecessary, and that they contribute to the creation of misconceptions about burns. In addition, these incisions can somehow trigger complications that can be avoided by using the concept of escharotomy in multiple directions, as highlighted in this review.

Helicopter Transport in Regionalized Burn Care: One Program's Perspective

BACKGROUND

The decision to use helicopter EMS (HEMS) for the transport of burn patients is a complex decision. This analysis sought to evaluate burn patients flown to burn centers who met predetermined criteria for patients who likely benefit from HEMS care.

METHODS

A retrospective transport chart review of all burn transports covering the preceding nine and a half years was conducted to evaluate for HEMS appropriate criteria defined as patients requiring advanced airway management, ventilator support, facial burns, inhalation injury, circumferential burns, electrical or chemical burn, or major burns. All ages were included.

RESULTS

A total of 171 cases were identified. Thirty-one (18.1%) were pediatric. Facial burns constituted the most frequent criteria met with 112 (65.5%) patients identified. Sixty-nine (40.4%) had suspected inhalation injuries. Fifty-five (32.2%) patients were intubated. Forty (28.6%) adults and twelve (38.7%) children had major burns.

CONCLUSION

Of the 171 burn patient transported, twenty-one (12.3%) patients did not meet any HEMS criteria. Excluding those who did not meet any criteria, 98 (57.3%) patients were flown with non-major burns. Efforts are needed to determine the risks burn patients face if slower, non-critical care transport is utilized and which patients are appropriate for HEMS.