3-14 Advanced Dermatological Procedures Flashcards
What are the general steps of dermatologic procedures?
- Evaluation of the wound or the area of the procedure
- Cleansing of the area
- Anesthetizing the area
- Complete the procedure or biopsy
- Follow up care and suture removal
How are wounds evaluated?
The wound is evaluated for damage to underlying structures, including:
nerves, tendons, vessels, joints, and bones,
as well as the presence of foreign bodies or body cavity penetration (e.g., peritoneum, thorax).
Failure to recognize these complications is one of the most significant errors in wound management
How are possible nerve injuries evaluated?
Suggested by sensory abnormality distal to the wound; suspicion is increased for lacerations near the course of significant nerves.
Examination should test light touch and motor function. Two-point discrimination is useful for hand and finger injuries.
Normal varies among patients and by location on injuries of the the hand; comparing findings on the identical site of the uninjured side is the best control.
How are possible tendon injuries recognized?
Complete tendon laceration usually causes a resting deformity (e.g, foot drop from Achilles tendon laceration, loss of normal resting finger flexion with digital flexor laceration) because forces from antagonist muscles are unopposed.
Resting deformity does not occur with partial tendon laceration, which may manifest with only pain or relative weakness on strength testing or be discovered only on exploration of the wound.
How should a tendon injury be evaluated?
The injured area should be examined through the full range of motion; the injured tendon may sometimes retract and not be visible on inspection or wound exploration when the injured area is in the resting position.
What are the SSXs of a vascular injury in a wound?
Suggested by signs of ischemia, such as pallor, decreased pulses, or perhaps delayed capillary refill distal to the laceration (all compared with the uninjured side).
Vascular injury is occasionally suspected in the absence of ischemia when a laceration traverses the territory of a major artery and is deep or complex or results from penetrating trauma.
Other signs of vascular injury can include a rapidly expanding or pulsatile mass or a bruit.
When should a bony injury be suspected?
Should be suspected particularly after penetrating trauma or when injury occurs over a bony prominence. If the mechanism or location of injury is concerning, plain x-rays are taken to rule out fracture.
When should foreign bodies be suspected in a wound?
Sometimes present in wounds, depending on the mechanism. Wounds involving glass are likely to have foreign bodies, lacerations from sharp metal rarely do.
Although not very sensitive, a patient’s complaint of feeling a foreign body is fairly specific and should not be ignored.
Localized pain or tenderness in a high-risk wound also is suggestive, particularly if pain worsens with active or passive motion.
How can possible foreign bodies in a wound be appreciated by a physician?
Wound examination and exploration are not sensitive for small foreign bodies unless the wound is superficial and its full depth is visible.
Imaging studies are recommended for all wounds involving glass and for other wounds if a foreign body is suspected because of the mechanism, the symptoms, or an inability to examine the wound’s full depth.
What imaging studies are good for evaluating different types of foreign bodies?
If glass or inorganic material (eg, stones, metal fragments) is involved, plain x-rays are taken; glass bits as small as 1 mm are usually visible.
Organic materials (eg, wood splinters, plastic) are rarely detected with plain x-rays
(although the outline of larger objects may be visible because of their displacement of normal tissue);
various other modalities have been used, including xerography, ultrasonography, CT, and MRI.
What are the contraindications to primary wound closure?
Concern about wound infection is the main reason not to close a wound primarily. If infection develops, the resultant deformity may be worse than that caused by the initial injury alone. The following circumstances are associated with an unacceptably high risk of infection:
An acute wound > 6 hours old (with the exception of facial wounds)
Foreign debris in the wound that cannot be completely removed e.g., a wound with a lot of embedded dirt that you cannot clean completely
Active oozing of blood
Dead space under the skin closure
Too much tension on the wound
What is delayed primary closure?
Delayed primary closure is a compromise between primary repair and allowing an acute wound to heal secondarily. It may be considered for a wound over 6 hours old even though primary closure is preferable such as a large wound or a wound near a skin crease
In delayed primary closure, you initially treat the wound with wet-to-dry dressing changes for a few (2–3) days with the hope of being able to suture the wound closed within 3–4 days.
How is a wound treated in delayed primary closure?
In delayed primary closure, you initially treat the wound with wet-to-dry dressing changes for a few (2–3) days with the hope of being able to suture the wound closed within 3–4 days.
During the few days of dressing changes, the reasons for not closing the wound initially may resolve. The dressings should clean the wound, the tissue swelling caused by the trauma may subside, and all bleeding may be fully controlled.
If the wound shows no signs of infection and can be closed without tension, it may be possible to close the wound primarily within a few days.
When should you seek a surgical consultation for laceration repair?
- Deep wounds of the hand or foot
- Full-thickness lacerations of the eyelid, lip, or ear
- Lacerations involving nerves, arteries, bones, or joints
- Penetrating wounds of unknown depth
- Severe crush injuries
- Severely contaminated wounds requiring placement of a drain
- Wounds leading to a strong concern about cosmetic outcome
How are wounds initially cleansed? Irrigated?
Saline or tap water may be used for wound irrigation, whereas povidone/iodine, detergents and hydrogen peroxide should be avoided.
Evaluating and cleansing a wound can hurt; remember pain control.
What agents are used for pain control? What are they good for? Contraindications?
Injectable lidocaine or bupivacaine should be used.
For wounds of the face or scalp, the addition of epinephrine decreases bleeding caused by the placement of sutures.
The effects of lidocaine last approximately 1 hour; the effects of bupivacaine last 2–4 hours
Epinephrine, which is used to decrease wound bleeding through vasoconstriction, should be avoided when wounds involve anatomic areas with end arterioles, such as the digits, nose, penis and earlobes.
How is pain control administrated?
Inject the anesthetic with as small a needle as possible.
A 25 gauge needle is acceptable, but use the smallest needle that you have.
Inject slowly. It is acceptable to inject into the wound after it has been cleaned. If the tissues are dirty, however, inject into the skin surrounding the wound to prevent foreign material from being pushed into the uninjured surrounding tissues.
Inject enough anesthetic to make the tissues swell just a little.
If the injury is in an area where a nerve block can be done (e.g., on the finger), do a nerve block. It provides better anesthesia.
Allow 5–10 minutes for the anesthetic to take effect.
The sting from a local anesthetic injection can be decreased by slow administration and buffering the solution.
To achieve the best cosmetic result, what should you consider in addition to technique?
Lines of Langer
•Consider the wound’s location in relation to Langer’s line before deciding the method and orientation of the closure
Check out this graph on wound repair:
