Escharotomy with an Enzymatic Debridement Agent for Treating Experimental Burn-Induced Compartment Syndrome in an Animal Model Yuval Krieger, MD, Lior Rosenberg, MD, Oren Lapid, MD, Ronen Glesinger, MD, Alex Bogdanov-Berezovsky, MD, PhD, Eldad Silberstein, MD, Amiram Sagi, MD, and Keith Judkins, FRCA Background: In patients with deep circumferential burns, adequate resolu- tion of burn-induced compartment syn- drome (BICS) is achieved by surgical escharotomy. Surgical escharotomy is traumatic, may cause considerable blood loss, does nothing toward debride- ment of the burn wound, and entails possible morbidity and complications. Debridase® is a bromelain-derived en- zymatic preparation capable of lysing the burn eschar within 4 hours, obviat- ing the need for surgical debridement. It has an affinity to burned necrotic tissue and does not damage healthy skin. In our clinical assessment of its efficacy, we found in several cases of deep burns of the limbs that the measured intracom- partmental pressure subsided after 2– 4 hours of Debridase® application, and none of the enzymatic escharotomy– treated patients suffering from circum- ferential burns developed BICS. To con- firm these observations, we conducted this controlled study. Methods: A model for BICS was de- veloped by making circumferential burns to pig legs and monitoring the anterior compartment of the legs. BICS was induced in the legs of 5 pigs (20 legs); 10 legs were treated with Debridase® and 10 served as nontreated controls, treated by surgical escharotomy at the conclusion of the experiment. Results: Debridase reduced BICS within 30 minutes from application. De- bridase was as effective as a standard sur- gical escharotomy. Conclusion: Escharectomy with an effective enzymatic debriding agent is po- tentially an adequate, simple, fast, effec- tive procedure to treat BICS; it has the added benefit of burn debridement with- out surgical escharotomy. Key Words: Burn-induced compart- ment syndrome, Escharotomy, Debride- ment, Bromelain, Debridase, Enzyme, Pig burn model. J Trauma. 2005;58:1259 –1264. D eep circumferential burns, with their characteristic rigid masses of burned tissue (eschar) may jeopardize limb viability owing to burn-induced compartment syn- drome (BICS). 1,2 When pressure increases in a confined anatomic space (compartment syndrome; CS) due to ex- travascular or extracellular fluid, it can adversely affect the circulation and thus the function and viability of the tissues therein. 3 As the intracompartmental pressure increases, it progressively surpasses the closure pressures of lymphatic vessels, veins, venules, capillaries, and arterial vessels, caus- ing their collapse and obstructing flow. 4 Capillary closure pressure of 30 mm Hg is the accepted threshold pressure for defining clinically meaningful CS, which requires therapeutic intervention. 5,6 BICS can result from progressive tissue edema of a severely burned limb that is enveloped in a noncompliant, rigid, burn eschar. 2,5 The classic symptoms and signs of CS (pain, pallor, paraesthesia, and hypothermia) may be masked by the burn-related symptoms, making the early diagnosis of BICS difficult. Furthermore, absence of distal arterial pulses cannot be relied on for early diagnosis, and when present, significant neuromuscular damage may have already occurred. 7 Failure to perform an adequate escharotomy when ap- propriate can result in irreversible tissue damage. Circular burns around the trunk may interfere with the normal respi- ratory function. Similar burns around the neck might interfere with airway patency and venous return. Thus, early resolution of BICS is essential. BICS is usually treated surgically by performing an escharotomy. This is a traumatic procedure, may destroy important struc- tures, causes significant blood loss, possibly increases the risk of sepsis, and often requires sedation or general anesthesia. Escharotomy by a simple, nonsurgical but effective proce- dure is likely to be less traumatic and to result in fewer long- term sequelae. Debridase®, a unique debriding agent currently under investigation (Biotechnology General, Inc., Nes-Ziona, Is- rael. At present Debridase® is produced by Mediwound Is- rael Ltd. under the name of Debridase-Debrase Gel Dressing.) 2 , is a bromelain-derivate enzyme mixture ex- Submitted for publication December 19, 2003. Accepted for publication February 2, 2005. Copyright © 2005 by Lippincott Williams & Wilkins, Inc. From the Department of Plastic and Reconstructive Surgery, and the Burn Unit, Soroka University Medical Center, Faculty of Health Sciences- Ben Gurion University of the Negev, Beer-Sheva, Israel and Pinderfields Burn Center, Mid Yorkshire Hospitals NHS Trust, Wakefield, England. Address for reprints: Lior Rosenberg MD Chairman Department of plastic and reconstructive surgery, and the Burn Unit, Soroka University Medical Center, Faculty of Health Sciences- Ben Gurion University of the Negev, Beer-Sheva, Israel POB 151 Beer-Sheva 84101 Israel; E-mail: proflior@netvision.net.il. DOI: 10.1097/01.TA.0000169867.08607.F1 The Journal of TRAUMA  Injury, Infection, and Critical Care Volume 58 • Number 6 1259