Indications for Referral and Initial Management
| Indications for Referral | Initial Management in the Office | |
|---|---|---|
| Hand burn | Partial-thickness burns >10% of TBSA | Apply dressings including bacitracin, mafenide acetate (sulfamylon), mupirocin (Bactroban), aquacel, biobrane, hydrocolloids, mepilex, xeroform, or acticoat7 |
| Third-degree burns | ||
| Burns involving major joints | ||
| Chemical or electrical burns | ||
| Inhalation injury or concomitant trauma | ||
| Special social, emotional, or rehabilitation needs | ||
| Trigger finger | Conservative and steroid treatments show no improvements. Provider is not comfortable with steroid injection to the stenosing tenosynovitis. | Activity modification |
| Splinting | ||
| Short-term nonsteroidal anti-inflammatory drugs | ||
| Hand laceration | Bite | Neurovascular exam |
| Laceration caused by teeth | Sensory exam | |
| Capillary refill greater than 2 seconds | Motor exam | |
| Exposed bones | Achieve hemostasis with pressure | |
| Contamination, early infection, and associated fractures | Irrigation with sterile or tap water | |
| Provider unable to close the soft tissue | Soft-tissue closure | |
| Pressure ulcers | Stage 3 and 4 wounds | Wound evaluation and staging |
| Bleeding control | ||
| Pressure reduction | ||
| Correct any existing malnutrition | ||
| Occlusive dressings | ||
| Venous wounds | Necrotic tissue debridement | Compression and leg elevation |
| Aspirin | ||
| Pentoxifylline | ||
| Arterial wounds | Wound with poor perfusion | Leg elevation |
| No improvements with conservative treatment | Management of modifiable risk factors | |
| Diabetic wounds | Refractory to conservative treatments | Wound culture |
| Deep ulcers reaching muscle or bony tissue | Antibiotic therapy | |
| Dressing changes | ||
| Patient education | ||
| Management of risk factors | ||
| Lymphedema | Stage III | Decongestive therapy |
| Patient education | ||
| Skin tears | Open fractures, tendon, nerve, muscle lesions, or skin tears in the eyelids | Moist dressings: aquaphor, hydrogel, or bacitracin. |
| Delayed healing (> 21 days) | Encourage fluid intake | |
| Scar management | Scars present for more than 1 year | Structured scar assessment |
| A concerning scar assessment | Subjective evaluation | |
| Keloids, recurrent scars, contracture scars, atrophic scars, widespread scars, or patients with a positive family history of abnormal scarring | Compression therapy | |
| Dynamic and static splints | ||
| Antihistamines | ||
| Hydrotherapy |
TBSA, Total body surface area.