Circumferential Burns
Objective: Recognize a burn that wraps the chest or a limb. Protect the airway. Cool briefly, then keep the patient warm. Do not cut an escharotomy in the field. Eschar is the stiff, leathery full-thickness burn.
Why this matters
Eschar is the stiff, leathery full-thickness burn. It does not stretch. If it wraps the chest, the patient cannot expand the chest, and ventilation can stop. If it wraps an arm or a leg, it can threaten the pulse the way a tight cast does. Both problems need a surgeon. Name them early. An escharotomy is a surgical cut through that eschar. Do not cut one in the field.
The other burn problem you can control is hypothermia. Cool only while heat is still in the tissue. After that, keep a large burn warm.
- Face, voice changes, soot, or a closed-space fire: early airway watch. See burn assessment and smoke inhalation.
- Chest eschar with rising work of breathing needs oxygen and a hospital that can do an escharotomy. Do not cut the chest in the field.
- Cool running water briefly on the burn that is still hot. Then dry, cover, and keep the patient warm. Do not use an ice bath. This page does not give a Parkland formula.
- This burn wraps the chest. Work of breathing is increasing. We are not cutting it.
- Limb pulses are changing. I am telling the receiving team now.
- Cooling is done. Now we keep them warm.
Clinical sequence
- Stop the burning. Remove charred clothing that is not stuck. Jewelry comes off a burned limb before it swells.
- Give oxygen and watch the airway. On a circumferential chest burn, recheck respiratory rate, work of breathing, and oxygen saturation. If the patient tires, use your usual airway steps. The eschar is why they are tiring. It does not change the oxygen plan.
- Cool a burn that is still hot with cool running water for a short period, the way your burn protocol times it. Then cover with a clean dry dressing. A large burn patient gets a warm ambulance. Ice and prolonged soaks drop the temperature.
- Check pulses and capillary refill beyond a circumferential limb burn. Mark what you felt and tell the hospital if the pulse fades. Elevation is reasonable if it does not cause pain you cannot manage. An escharotomy is a surgical procedure.
- Estimate size honestly for the destination decision. Fluids, if your protocol starts them, follow that card. Do not run a Parkland calculation from memory as an order.
Teaching points
- American Burn Association teaching sends circumferential chest and limb burns to a team that can operate. In the field, identify the burn and package the patient.
- A rising respiratory rate and a falling breath size, with a stiff burned chest, is a destination and airway problem. Needle decompression does not fix eschar.
- Chemical and electrical burns have their own lessons. A circumferential electrical burn still needs the same pulse checks, plus the heart monitor from electrical injury.
Common errors
- Cutting an escharotomy because a video made the cut look simple.
- Icing a large burn until the patient is shivering.
- Forgetting to tell the hospital that a limb pulse disappeared en route.
Practice
One-minute check
A patient has a leathery burn around the whole chest and is speaking in shorter sentences than ten minutes ago. Say the oxygen plan, the procedure you will not perform, and when cooling stops.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- American Burn Association resources — circumferential burns that impair breathing or circulation need surgical care. Escharotomy is not a field procedure on this site
- NASEMSO National Model EMS Clinical Guidelines (2022) — burn fluid volumes and destination stay on the local protocol
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.