Indications for escharotomy of a circumferentially burned right lower limb include all of the following except:

B. Coolness of the unburned skin of the toes of the right foot

D. Edema of the unburned skin of the right foot.

DISCUSSION: The blood flow to distal and underlying unburned tissue in a limb can be compromised by vascular compression due to edema formation beneath the unyielding eschar of a full-thickness circumferential burn. The most reliably noninvasive means of monitoring adequacy of the circulation in a circumferentially burned limb is serial examination using the ultrasonic flowmeter. The absence or progressive diminution of pulsatile flow in the posterior tibial artery in the lower limb or the palmar arch arteries in the upper limb indicates a need for escharotomy. Delayed capillary refilling, cyanosis of the digits, and progressively severe paresthesias, particularly deep tissue pain, are all clinical signs that may indicate vascular compromise and should be monitored if an ultrasonic flowmeter is not available. Persistent deep tissue pain and progressively severe paresthesias are the most reliable of the nonspecific clinical signs. A muscle compartment pressure that exceeds 30 mm. Hg, which is greater than normal capillary pressure, has also been used as an indication for escharotomy in burn patients. Edema and coolness to the touch of distal unburned tissue commonly accompany thermal injury and are not useful in assessing the need for escharotomy.