advanced derm procedures Flashcards
steps of derm 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
wound evaluation include
evaluating for damage to underlying structures and presence of foreign bodies or body cavity penetration
wound evaluation - nerve injury
neuro exam: light touch and motor function; 2-point discrimination for hand and finger injuries
compare findings to uninjured side
wound evaluation - tendon injury
complete tendon laceration causes resting deformity (foot drop when Achilles tendon laceration); partial tendon laceration does not cause resting deformity
exam: full ROM
wound evaluation - vascular injury
suggested by signs of ischemia, rapidly expanding or pulsatile mass or bruit
wound evaluation - bone injury
plain X-ray to rule out fracture
wound evaluation - foreign bodies
- wounds involving glass usually have foreign bodies, lacerations from sharp metal rarely do
- localized pain or tenderness, esp if pain worsens with motion
- imaging studies for all wounds involving glass and other suspected foreign bodies
- x-ray for glass, metallic; other modalities for organic materials (ex: wood splinters or plastic)
contraindications for primary wound closure
concern about wound infection. circumstances assoc with high risk of infection:
- acute wound > 6hrs
- foreign debris that can’t be completely removed
- active oozing of blood
- dead space under the skin closure
- too much tension on the wound
delayed primary closure definition
compromise between primary repair and allowing an acute wound to heal secondarily
delayed primary closure considered for which type of wound?
wound >6hrs even though primary closure is preferable such as a large wound or a wound near a skin crease
delayed primary closure procedure
- treat the wound with wet-to-dry dressing changes for a few days
- suture the wound closed within 3-4 days
when to seek surgical consultation for laceration repair
- deep wounds of hand or foot
- full-thickness lacerations of the eyelid, lip, or near 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
cleanse with what? what should be avoid?
cleanse with saline or tap water
avoid povidone/iodine, detergents and hydrogen peroxide
where to anesthesize to minimize pain when cleansing wound?
anesthesize around the wound, not in the wound
anesthetize with what? and how long does it last?
lidocaine (last 1hr)
bupivacaine (last 2-4hrs)
where can you use anesthetic agent + epinephrine? where can you not use it?
can add epinephrine for wounds of face or scalp
can’t add epinephrine for wounds of digits, nose, penis, and earlobes
administration of anesthetic
- inject with a needle as small as possible
- inject slowly and in skin surrounding wound
- do a nerve block isntead of anesthetic if possible
- sting from anesthetic can be decreased with slow administration and buffering solution
non-absorbable suture
- silk - lowest tensile strength
- nylon - high tensile strength, but requires a number of knots
- polypropylene (prolene) - low tissue reactivity and high tensile strength, but requires extra knots, can stretch to accommodate wound swelling
- cotton
- stainless steel
absorbable suture
- catgut - retain tensile strength for 5-7 days
- chromic gut - retains tensile strength for 10-14 days, used to close oral mucosa laceration because rapidly absorbed
- fast-absorbing gut - epidermal suturing especially for facial lacerations, retain strength for 5-7 days, low tensile strength
- polyglactin (vicryl) - ideal for subcutaneous sutures
- monocryl - for facial lacerations closed with subcuticular running sutures
- polyglycolic acid (dexon)
interrupted suture:
used for which wounds?
advantage?
used for wounds that are jagged or irregular
advan: allows for removal of some sutures in cause of infection, suture breaks still have remaining sutures in place
continuous suture
advantage?
disadvantage?
advantage:
- closes wound quickly
- gives better cosmetic result since tension spread uniformly
disadvantage:
1. suture breaks, entire wound opens
subcuticular running suture
used for which wounds?
- for low-tension, cosmetically important wounds
vertical mattress suture used for which wounds?
everting wound edges in locations that tend to invert
horizontal mattress suture used for which wounds?
high-tension wounds or wounds with fragile skin
layered closure:
when to do it
how to do it
what happens if not done
- when wound is widely separated or closure will be under some tension
- use dermal sutures by placing absorbable suture under epidermis
- not done -> seroma in open space
tissue adhesives advantage
applied quickly
no anesthesia required
eliminate need for follow-up
tissue adhesive contraindicated in which patients
immunosuppressed patients
diabetics
tissue adhesive not used in which wounds?
- high-tension areas such as over joints
- mucosal surfaces
- wound that are contaminated, complex, jagged
biopsy types
- incisional
shave - superficial portion of suspected area is removed
punch - small cylinder of tissue is removed - excisional - entire area of abnormal tissue is removed (ellipitcal shape)
at how many weeks do the wounds look the worst? when does it shrink down?
- looks angriest at 1mo - 6wks
2. shrink down in 1yr
aftercare
- After suturing the wound closed, apply a small amount of antibiotic ointment over the suture line and cover the area with a dry gauze.
- After 24 hours, remove the original dressing.
- The patient can wash the area with gentle soap and water the day after the repair. A shower is fine, but if the patient wants to take a bath, the injured area should not be allowed to soak in the water for more than a few minutes.
- A small amount of antibiotic ointment can be applied daily for the first few days; then leave the area open to air.
- If the injured area is on the hand, foot, or calf, have the patient elevate the affected extremity. Elevation decreases swelling in the injured area and thereby improves healing.
- Applying white petrolatum to a sterile wound to promote wound healing is as effective as applying an antibiotic ointment although neither is necessary and may delay wound healing.
when can suture be removed
face - 3-5 days scalp - 7-10 days arms - 7-10 days trunk - 10-14 days legs - 10-14 days hands or feet - 10-14 days palms or soles - 14-21 days
how to decreased scarring
skin sutures are removed while the scar tissue is still relatively weak compared with the final scar strength (which is not attained for several months).
how to maintain wound closure after sutures are removed
it is useful to place Steri Strips (if available) across the scar once the sutures have been removed. These strips fall off on their own, and the patient can wash the area, even with the strips in place
