3- Skin and Soft Tissue Disorders Flashcards
What indicates a tetanus-prone wound?
> 6 hrs old
Deep (> 1cm)
Grossly contaminated
Avulsion/ puncture/ crush
What is the most common pathogen a/w animal bites?
(oral flora of biting animal and human skin)
Pasteurella
Dog bites are most common in children of what age/ where?
< 10 yo, head + neck
Cat bites often result in deep wounds due to long slender teeth. Punctires below the periosteum may lead to what?
Osteomyelitis or septic arthritis
What pathogens are most commonly a/w human bites? (3)
Eikenella Corrodens
Group A strep
Staph
What must you check for when a pt presents with a human bite?
Meaure- maxillary inter-canine distance is > 2.5cm = adult bite
(child abuse)
What is included in the mangement of bite wounds?
X-ray
Clean surface- povidone iodine
Clean depths- copious irrigation
When is a surgical consult indicated for a bite wound?
Deep/ penetrating to bones, tendons, joints
Complex facial lacerations
Neurovascular compromise
Complex infections
When are prophylactic abx indicated for a bite wound?
Deep/ require closure
IMC
Mod-severe + a/w crush injury
Venous/ lymphatic compromise
Hands, genitalis, face, close contact w/ bone/ joint
What is the most common plantar puncture?
Stepping on a nail
What imaging is indicated for a plantar puncture?
X-ray
What should be done after occurence of a needle stick injury?
Cleanse w/ soap, water, alcohol
Determine HIV status (B + C)
What are the indications for closure aside from decrease healing time, reduce likelihood of infection, decrease scar function, and improve cosmesis?
Extension into sub Q
Repair loss of structure or function
What are the contraindications for closure of a wound?
Contaminated/ presence of FB
> 12 hrs old
Wounds involving: tendons, nerves, arteries
What are complications of closure, aside from infection, scars, loss of function, and loss of cosmesis?
Wound dehiscence (wound reopens and has to close by secondary intention)
Tetanus
What type of wound has involvement of GU, GI, and respiratory tracts?
Clean-contaminated
What type of wound has gross spillage into the surgical wound (bile, stool)?
Contaminated
(typically traumatic)
What type of wound closure is used for clean/ clean-contaminated wounds, involves closure of all layers, and results in minimal scarring?
Primary intention
What type of wound closure involves closure of deep layers but allows for granulation of superficial laters, and can leave a wide scar?
Secondary intention
(requires frequent wound care)
What type of wound closure involves closure of deep layers followed by closure of superficial layers 4-5 days later after infection is not a concern?
Delayed primary intention
What type of sutures are absorbable?
Vicryl
PDS
Chromic gut
What type of sutures are nonabsorbable?
Prolene
Nylon
What type of suture method is frequently used to close skin lacerations?
Simple interrupted
What type of suture method is useful for deep wounds and helps eliminate dead space?
Vertical mattress
What type of suture method is useful in flaps or wounds under tension?
Horizontal mattress
What type of suture method provides tighter closure if locked?
Continuous
What type of suture method is often used for surgical or clean wounds and must be performed with absorbable suture?
Subcuticular
What are defined as skin tension lines that indicate orientation of collagen fibers?
Langer’s lines
Lacerations @ right angles to lines tend to gape
How long should a suture site be kept clean and dry?
No contact w/ water for 48 hours
When should sutures generally be removed based on body location?
Face, ear = shortest (~4-5 days)
Scalp, trunk, extremities (~7-14)
Hand, foot, fingertips = longest (~8-14)
When are antibiotics indicated for wound repair?
(aside from bites, crush wounds, contaminated wounds, IMC)
> 12 hrs old (esp on hands)
Avascular areas (ex. ear)
Joint spaces, tendon, bone
Hx of valvular heart disease
Does hair need to be shaved off prior to suturing?
No (can increase risk of infection and leave particles in wound)
What is the most important means to decrease infection risk?
Irrigation
When are suture wounds re-checked?
24-48 hrs
+ additional re-check in 48-72 hrs if highly contaminated
Pt presents with localized pain, swlling, tenderness, erythema and warmth but absence of abscess, purulent drainage or ulceration. You suspect an acute infection that does not involve fascia or muscles. What is this called?
Cellulitis - nonnecrotizing inflammation of skin + subq tissues
What is the most common etiology of cellulitis for immunocompetent vs IMC pts?
Immunocompetent- A strep, S. aureus
IMC- Pseudomonas
What signs/ sxs of cellulitis indicate deep soft-tissue infection and therefore require emergent sugical eval? (6)
Violaceous bullae
Cutaneous hemorrhage
Skin sloughing
Skin anesthesia
Rapid progression
Gas in tissue
Outpt care of cellulitis is indicated for mild, local sxs w/o evidence of systemic disease. What is included in care?
(strep most likely pathogen)
Limb elevation, empiric abx x 5 days
F/u 48-72 hrs
When is inpatient management for cellulitis considered (aside from IMC and comorbidities)?
Facial cellulitis of odontogenic origin
Orbital cellulitis
Cellulitis affecting > 1/4 of extremity
What is 1st line abx treatment for cellulitis?
Beta-lactams x 10-14 days
(Amoxicillin, amoxicillin- clavulante)
How is recurrent cellulitis defined and what is the tx?
3-4 episodes/ yr (usually due to venous/ lymphatic obstruction)
Penicillin/ Erythromycin BID x 4-52 weeks
Hx of MRSA, break in skin, and IMC puts pts at increased risk for what?
Abscess
When do abscesses require surgical referral for drainage? (5)
(body locations)
Perirectal
Neck
Hand
Breast (near aeola/ nipple)
Adjacent to vital nerves/ blood vessels (facial nerve, carotid/ femoral artery)
What is included in the home care for abscesses and when should the pt f/u?
Change packing q 24 hrs
If recurrent infections- bathe w/ chlorhexidine daily
F/u 24-48 hrs
Cellulitis with abscess or recurrent abscesses may indicate a MRSA infection. What is included as part of the 5 day decolonization regimen?
BID nasal mupirocin
Daily chlorhexidine washes
Daily decontamination of personal items (towels, sheets)
If pt with a burn wound infection develops cellulitis, what drugs should prescribed for tx?
IV Cefazolin/ Clindamycin/ Vancomycin
What is defined as an infection of the deep soft tissues, and results in progressive destruction of muscle fascia/ overlying sub-q fat?
Necrotizing fasciitis
What is spared in necrotizing fasciitis and what is the likely pathogen?
Spares muscle
GAS or beta-hemolytic strep
Pt presents with severe pain starting in the anterior abd wall and migrates to gluteal muscles, scrotum and penis. You note tense edema outside the involved skin, blisters/ bullae, crepitus, and sub-q gas. Systemic sxs include fever, tachycardia, and hypotension. What are you concerned for and what is the tx?
Fournier’s Gangrene
Aggressive surgical debridement + broad spectrum abx
