Advanced Derm Procedures (Kief) - SRS Flashcards
What structures should a wound be evaluated for prior to treating a wound?
- Nerves
- tendons
- vessels
- joints
- bones
- foreign bodies
- body cavity penetration
See sensory abnormality distal to wound = ?
High suspisioun of laceration near course of major nerve
How should you examine for nervous abnormalitis related to wounds?
Light touch
Motor function
2 point discrimination
(compare bilaterally)
A complete tendon laceration causes what kind of deformity?
Resting deformity - eg achilles tendon laceration = foot drop
d/t unopposed muscle groups
How should tendon injuries be evaluated?
through the full range of motion - tendon may have retracted and not be visible when in resting position.
Vasular injury is 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). Or when a laceration traverses the territory of a major artery and is deep or complex or results from penetrating trauma.
What are some other signs of vascular injury?
a rapidly expanding or pulsatile mass or a bruit
When should a bone injury be suspected?
How would you rule out?
- based on nature of MOI
- Should be suspected particularly after penetrating trauma or when injury occurs over a bony prominence
- plain x-rays are taken to rule out fracture.
Foreign bodies are Sometimes present in wounds, depending on the mechanism. Wounds involving glass are likely to have foreign bodies, lacerations from sharp metal rarely do. What suggests a foreing body might be present?
What is critical in evaluating this?
Localized pain or tenderness in a high-risk wound also is suggestive, particularly if pain worsens with active or passive motion.
Also, if patient thinks something is in there.
Important to retract the wound a visualize full depth
Wound examination and exploration are not sensitive for small foreign bodies unless the wound is superficial and its full depth is visible. What should be done for inorganic and organic foreign bodies?
Imaging studies,
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.
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. What are 5 circumstances are associated with an unacceptably high risk of infection? (contraindications to primary wound closure)
- 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 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, what is the approach to this?
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.
When can you make the call to close the wound?
If the wound shows no signs of infection and can be closed without tension,
Under what circumstances should you seek surgical consult for laceration repair? 7
- 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
What should be used to irrigate a wound?
What should specifically not be used?
What should you not forget to do?
USE
- saline
- tap water
Do not use
- providone/iodine
- detergents
- hydrogen peroxide
Do not forget
- To anesthatize the wound
Generally what agents are good for anethetizing wounds?
Injectable lidocaine or bupivacane
For wounds of the face or scalp, the addition of what decreases bleeding by suture placement?
Epinephrine
How long does the effect of lidoicaine last?
Bupivacaine?
Lidocaine - 1 hr
bupivavaine - 2-4 hours
In what situations is epinephrine CI?
digits
nose
penis
earlobes
Children: use with caution
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.
What is better than loval anesthetic?
NErve block is better if possible.
What should you try to adhere to when closing, or excising stuff?
Wounds location in relation to Langer’s lines.
What is silk suture material used for?
Larger surgical wounds
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
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). What is a rather unique characteristic of this material?
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
Catgut — Catgut is a natural product derived from sheep or cattle intima. Plain catgut retains significant tensile strength for only five to seven days. Chromic gut is treated with chromium salts to resist body enzymes, thus delaying absorption time. How long does it retain tensile strength?
10 to 14 days
What is the main use of chromic gut?
to close lacerations in the oral mucosa. Chromic gut is more rapidly absorbed in the oral cavity than most synthetic sutures, making it ideal for this environment.
When is chromic gut less useful?
less optimal for use in dermal (subcutaneous) and muscle layer closures because of increased tissue reactivity.
What absorbable material is useful for epidermal suturing?
Fast-absorbing gut
What type of suture is described here?
Introduced in 1974, is a lubricated, braided synthetic material with excellent handling and smooth tie-down properties. It retains significant tensile strength for three to four weeks. Complete absorption occurs in 60 to 90 days. It has decreased tissue reactivity compared with catgut as well as improved tensile strength and knot strength. is an ideal choice for subcutaneous sutures.
Polyglactin 910 (Vicryl)
What type of suture material is described here?
is a monofilament suture that has superior pliability for easier handling and tying of knots. Its monofilament quality gives it a theoretical advantage over braided sutures for contaminated wounds requiring deep sutures. This suture is often used by plastic surgeons at our institution for facial lacerations closed with subcuticular running sutures. All of its tensile strength is lost by 21 days postimplantation
Poliglecaprone 25 (Monocryl)
Type of suture material described here?
It is a braided polymer, is less reactive than gut sutures, and has excellent knot security. It maintains at least 50 percent of its tensile strength for 25 days [13]. The main drawback is a high friction coefficient causing “binding and snagging” when wet. Newer forms of this suture have been developed, Dexon Plus and Dexon II, which have an added synthetic coating to improve handling properties while maintaining knot security
Polglycolic acid (Dexon)
The interrupted technique is easy to learn and do and allows for removal of only some of the sutures in cases of infection.
What is this best for?
What is another benefit of this?
Wounds that are jagged or irregular.
•If a suture breaks, the remaining sutures remain in place.
The Continuous Technique, also called a baseball stitch closes the wound quickly.
What are some benefits of this?
What is a down side?
- Generally gives a better cosmetic result since tension is spread uniformly along the wound edges
- If the suture breaks the entire wound opens
What suture technique is good for low-tension, cosmetically important wounds
Subcuticular running suture
What can be done to make the continuous technique work better?
Have an assistant to perform the following technique to maintain tension
What suture technique should be used for everting the wound edges in anatomic locations which tend to invert?
Vertical mattress suture
What is a good suture material to use for subcuticular running sutures?
Vicryl
What suture type is best for high tension wounds or wounds in fragile skin?
Horizontal mattress technique
What size needle should be used for a vertical mattress suture?
A big, curved one.
Although most wounds require only skin closure, sometimes it is necessary to close the wound in layers.
The layers may involve?
Muscle
Fascia
Dermis
If the wound is widely separated or the closure will be under some tension, what should be used here?
A few buried dermal sutures are useful - placed just below epidermis and made of absorbable material.
Suturing is the preferred technique for skin laceration repair however an alternative exists, what is it?
tissue adhesives such as 2-octylcyanoacrylate (Dermabond), are comparable with sutures in cosmetic results, dehiscence rates, and infection risk
What type of wounds are adhesives not good for?
Tissue adhesives’ low tensile strength makes them inappropriate for high-tension areas, such as over joints, unless the area is immobilized.
In what patients are tissue adhesives CI?
Immunosuppressed patients
Diabetics
What wounds should not get tissue adhesive treatment?
Contaminated
Complex
Jagged
They should also be avoided on mucosal surfaces and areas that maintain moisture, such as the groin or axillae.
What are the two incisional biopsies?
Shave biopsy—The superficial portion of the suspect area is removed.
Punch biopsy—A small cylinder of tissue is removed using a punch tool.
What happens in an excisional biopsy?
The entire area of abnormal tissue is removed.
What are the three phases of wound repair after acute injury?
Inflammation
Proliferation
MAturation
Wound location Timing of removal (days)
Face
Scalp
Arms
Trunk
Legs
Hands or feet
Palms or soles
Wound location Timing of removal (days)
Face Three to five
Scalp Seven to 10
Arms Seven to 10
Trunk 10 to 14
Legs 10 to 14
Hands or feet 10 to 14
Palms or soles 14 to 21
To decrease 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). What should be done to help maintain the wound closure?
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.
