AN ALGORITHM FOR STANDARIZED CARE AND ASSESSMENT OF HAND BURNS

Rosenberg L., Shani E., Greber B., Carmel C., Sagi A.

Soroka University Hospital & The R&D Center for Plastic Surgery Advanced Services, Israel

SUMMARY. The objective assessment of all factors involved in the treatment of hand bums is the indispensable basis of our body of knowledge of the subject, especially knowledge gathered by large numbers of observers and centres with direct or indirect bias. Such critical assessment has to be based on well-defined criteria known to all participating members. The different criteria have to follow a logical sequence based on the entire natural and dynamic course of the pathological and therapeutic process. Such a flow chart of clinical findings, decisions and alternatives forms an algorithm. We present the algorithmic process of hand bums care and assessment of our Centre. The algorithm itself has been successfully implemented in our service. We appeal to other centres to join our efTort of establishing, collecting and editing similar algorithms into a reference manual.

1. Name: date of birth: I.D.: today's date: date of bum: time of bum: cause of bum: area of bum: CM2 (Total) c:] volar r:i, dorsal [I fingers (Include body surface area burn chart) History of allergy to:

• antibiotics (specify)
• iodine
• nitrofurazone

History of joint disease, disease type

2. Initial examination

• Depth assessment
• superficial first degree CM2
• superficial second degree CM2
• deep second degree CM2
• third degree or worse CM2
• superficial is all that can be determined CM2
• circular
• escharotomy done
• presence of infection
• cellulitis
• purulent exudate
• small exudate clean burn
• oedema
• serious slight no oedema
• type of bandage applied after initial examination
• Depth assessment
• superficial first degree CM2
• superficial second degree CM2
• deep second degree CM2
• third degree or worse CM2
• superficial is all that can be determined CM2
• circular
• escharotomy done

3. Primary assessment

• presence of infection
• cellulitis
• purulent exudate
• small exudate
• clean bum
• occupational therapy consulted type of bandage applied

4. Surgical treatment

• Operative procedure
• tangential excision
• other excision (type)
• split thickness non-mesh graft
• other graft (specify)
• immediate grafting
• delayed grafting
• reason:
• graft site clean
• graft site dirty

5. Surgical patient assessment
(to be used every time a surgical patient is examined)

• haematoma
• displaced graft
• dandage is dry and adhesive
• cellulitis
• exudate
• location:
• description:

other complications:

treatment including patient instructions: occupational therapy consult next exam planned: (days)

6. Surgical patient discharge

• post-op day of discharge:
• plan and instructions given to patient:
• patient seems L] reliable E] cooperative 11 interested in self-help
• date of return to clinic:

7. Conservative treatment patient assessment
(to be used every time a patient treated conservatively is examined)

• bandage is dry and adhesive
• exudate
• cellulitis
• necrosis
• excess granulation tissue
• adequate granulation tissue
• other problems with bum:
• treatment including patient instructions:
• occupational therapy consult next examination planned:

8. Conservative treatment patient discharge

• total epithelialization 1:1 no total epithelialization
• reason for discharge:
• plan and instructions given to the patient:
• patient seems [I reliable F-] cooperative E interested in self-help
• date of return to clinic:
• itching
• pain
• patient is exercising

9. Follow-up

• appearance of wound: j contractures [3 thumb E] syndactyly Ei little finger
• instructions given to the patient:
• treatment given to patient:
• occupational therapy plan:
• treatment: date of return to clinic:

removal of any blisters cover with nitrofurazone gauze cover with thick absorbent dressing use elastic bandages

removal of any blisters cover with nitroftirazone gauze cover with Betadine-soaked gauze cover with thick absorbent dressing use elastic bandages

open passive dressing

removal of any blisters cover with nitrofurazone gauze cover with saline-soaked gauze cover with thick absorbent dressing use elastic bandages

same steps as 4/A use continuous infusion of saline

removal of any blisters cover with nitrofurazone gauze cover with Betadine- or neomycin-streptomycin soaked gauze cover with thick absorbent dressing use elastic bandages

same steps as 5/A use continuous infusion of neomycin-streptomycin or Betadine

removal of any blisters cover with nitrofurazone gauze cover with M9S04 cover with thick absorbent dressing use elastic bandages

Protocol 6/B

same steps as 6/A use continuous infusion Of M9S04

Protocol 7

removal of any blisters apply silver sulphadiazine to bum use plastic bag covering

removal of any blisters apply silver sulphadiazine to burn cover with thick absorbent dressing use elastic bandages

removal of any blisters apply debridement agents (e.g. Aserbin) cover with thick absorbent dressing use elastic bandages

removal of any blisters apply debridement agents (e.g. Aserbin) apply silver sulphadiazine to bum cover with thick absorbent dressing use elastic bandages

RÉSUMÉ. L'évaluation objective de tous les facteurs relatifs au traitement des brûlures des mains constitue la base indispensable pour l'ensemble de nos connaissances du sujet, et en particulier les connaissances recueillies par un grand nombre d'observateurs et de Centres avec un intérêt direct ou indirect. Cette évaluation critique doit être basée sur des critères bien définis reconnus par tous les participants à la recherche. Les différents critères doivent suivre une séquence logique basée sur tout le cours naturel et dynamique du processus pathologique et thérapeutique. Cet ordinogramme des résultats cliniques, des décisions et des alternatives forme un algorithme.
Nous présentons l'algorithme utilisé dans notre Centre pour la thérapie et l'évaluation des brûlures des mains. Nous invitons les autres Centres à coopérer pour créer, recueillir et éditer des algorithmes similaires dans un manuel de référence.