Advanced Derm procedures Flashcards
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
Wound Evaluation
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.
Wound Evaluation-Nerve Injury
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.
Wound Evaluation-Tendon Injury
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.
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.
Wound Evaluation-Vascular Injury
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.
Wound Evaluation-Bone Injury
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.
Wound Evaluation-Foreign Bodies
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.
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.
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.
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
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.
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.
Guidelines for SeekingSurgical 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
Cleanse
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.
Anesthetize - Agents
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.
Anesthetize - administration
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.
Lines of Langer
Consider the wound’s location in relation to Langer’s line before deciding he method and orientation of the closure
Complete the procedureNon Absorbable Suture
Silk –Silk is a natural product that is renowned for its ease to handle and tie. It has the lowest tensile strength of any nonabsorbable suture. It is rarely used for suturing of minor wounds because stronger synthetic materials are now available.
Nylon (Dermalon, Ethilon)– Nylon was the first synthetic suture introduced; it is popular due to its high tensile strength, excellent elastic properties, minimal tissue reactivity, and low cost. Its main disadvantage is prominent memory that requires an increased number of knot throws (3 to 4) to hold a suture in place [13].
Polypropylene (Surgilene, Prolene) – Polypropylene is a plastic, synthetic suture that has low tissue reactivity and high tensile strength similar to nylon. It is slippery and requires extra throws to secure the knot (4 to 5). Prolene is especially noted for its plasticity, allowing the suture to stretch to accommodate wound swelling. When wound swelling recedes, the suture will remain loose. The cost of Prolene is approximately 13 percent more than nylon [5]. Prolene can be purchased in a blue color, which can be advantageous in localizing sutures in the scalp and dark-skinned individuals.
Cotton
Stainless steel
