All subjects Flashcards
1
Q
Common rash-first few days after birth
Small blotchy erythematous areas with a raised yellow/white center***
May be anywhere, including palms and soles, esp. on trunk
Usually in first week to ten days of life; up to 4 weeks ***
Dissipate without treatment in 5-7 days***
Cause is unknown
Harmless
Biopsy shows eosinophil’s
A
erythema toxicum
2
Q
what is moniliasis
A
beefy red with satellite lesions
diaper rash
use nystatin ointment
3
Q
3-5% of children 6 mo to 10 yr
Ill-defined, red, pruritic, papules/plaques
Diaper area spared***
Acute: erythema, scaly, vesicles, crusts
the itch that rashes
A
this is atopic dermatitis (eczema)
Chronic: scaly, lichenified, pigment changes
Cause: unknown; ? combo dry, irritated skin w/ malfunction of immune system; ?genetic basis ?food causes flare
4
Q
treatment of atopic dermatitis
A
gets better with steroid cream (topical steroids)
Antihistamines for itching
After showers, moisturize with thick ointments QUICKLY afterwards, don’t wipe completely dry
Vaseline, Aquaphor, Cetaphil, Eucerin, Vanicream
Dove unscented
5
Q
Abdominal pain, rash on legs (nonblanching and raised), arthritis in ankles
Laboratory tests are usually normal (platelets, complement level, and antinuclear antibodies) except for the urinalysis, which may be positive for blood or protein in 50% of the patients
A
Henoch shonlein purpura
HSP is a systemic vasculitis** of small** vessels characterized by 2- to 10-mm erythematous hemorrhagic papules in a symmetric acral distribution, over the buttocks and extremities – palpable purpura***
Patients with HSP limited to the skin and joints can be managed as outpatients. Severe abdominvolvement inal pain, gastrointestinal hemorrhage, intussusception, and severe renal are indications for admission.
6
Q
what is the most frequent and serious complication of HSP
A
Renal involvement is the most frequent and serious complication and usually occurs during the first month. It commonly manifests itself as acute glomerulonephritis. Hypertension is uncommon
7
Q
Still’s murmur?
A
Still’s: low-pitched sounds heard at the lower left sternal area, “musical.” These most commonly occur between age 3 and adolescence. Low pitched - best heard with the bell of the stethoscope. Can change with alteration of position and then can decrease or disappear with the Valsalva maneuver (valsalve decreases preload) . No clicks are present.
8
Q
Bounding pulse, murmur Tachypnea Poor feeding habits Shortness of breath Sweating while feeding Tiring very easily poor growth
A
patent ductus arteriosus
Failure of closure of ductus arteriosus within a few days after birth
Girls>boys
More common in premature infants, neonatal respiratory distress, infants w/ genetic d/o (such as Down syndrome) & those w/ congenital heart lesions
Small PDAs usu. asymptomatic
9
Q
5 T’s of cyanotic congenital heart disease
A
Tetralogy of Fallot
1. VSD 2. Overriding aorta 3. RV outflow obstruction 4. RV hypertrophy
Transposition of the Great Arteries
TAPVR- total anomalous pulmonary venous return
Truncus arteriosus
Tricuspid Atresia
10
Q
steeple sign
most common cause of inspiratory stridor *** in peds at rest
viral in origin
A
laryngotracheobronchitis (croup)
subglottic narrowing of the trachea = steeple sign
Coryza 1-2d prior to croupy cough, hoarseness, & stridor
treat with inhaled epi and oral steroids
pt’s that have the bacterial form are WORSE and get intubated
11
Q
Typically has an abrupt onset of symptoms Typically the school aged child Sore throat Fever Headache GI symptoms: abdominal pain, nausea, and vomiting Poor oral intake NO cough or rhinorrhea!!
A
strep pharyngitis (no viral symptoms)
Exudative pharyngitis or erythema of posterior orophayngeal mucosa
Enlarged tender anterior cervical lymph nodes
Palatal petechiae
Inflamed uvula
Scarlatiniform rash- little bumps all over
Pastia’s lines- AC fossa
12
Q
Important cause of chronic cough in toddler***
A
foreign body
Nasal
Unilateral purulent drainage
Foul smelling
Lower respiratory tract
DDx: recurrent viral infections and asthma
PE and CXR may be unrevealing
Hyperlucency of right hemithorax & shift of mediastinal structures to left on expiration (foreign body in right mainstem bronchus).
13
Q
Most common cause of diarrhea in young children throughout the world
A
rotavirus
there is a vaccine for this
14
Q
how do you treat labial adhesions
A
Tx: mechanical separation then petroleum ointment to diminish irritation
use estrogen creams (Premarin)- causes atrophy of the tissue and makes it unfused
15
Q
simple febrile seizure
A
Lasts a few seconds to 5-10 minutes
Followed by a period of drowsiness or confusion (30 minutes post-ictal)
16
Q
complex febrile seizure
A
lasts longer than 15 minutes
In just one part of the body
Occurs again during the same illness.
17
Q
gower maneuver
A
duchene’s muscular dystrophy
Progressive degeneration of skeletal muscle
1:3500 male births
X-linked recessive
Early onset, symmetrical, begins w/ pelvic/pectoral girdle involvement
Confined to wheelchair by adolescence
Death from cardioresp. Insufficiency by age 20
18
Q
Traction apophysitis of tibial tubercle
PE: tenderness/swelling at tibial tuberosity
A
osgood schlatter disease
M>F
Cause:
Differential rates of osseous & soft tissues
Stress on apophyses by vigorous physical activity
Pain often relieved w/ rest
Duration: 6-24 months
Tx: rest, NSAIDS, cast/splint (if severe)
Steroid contraindicated***
19
Q
Coxsackie A 16
Painful, shallow, yellow ulcers surrounded by red halos
Found on buccal mucosa, tongue, soft palate, uvula and anterior tonsillar pillars
Exanthem involves palmar, plantar and interdigital surfaces of the hands and feet +/- buttocks
A
hand foot mouth disease
At risk: preschoolers
Highly contagious
Incubation: 4-6 days
Prodrome: 1-2 days before rash
Low grade fever, anorexia, malaise, sore throat
Oral lesions without the exanthem = herpangina
20
Q
At risk: school age children (4-10) Season: sporadic Incubation: 4-14 days Infectious: until the onset of the rash Rash on face is characteristic “slapped cheek” appearance***
A
Erythema infectiousum (5th disease) parvovirus B19
> 50% asymptomatic
Prodrome
Mild fever (15-30%), sore throat, malaise
Dangerous for pregnant women in 1st trimester
Can cause hydrops fetalis***
21
Q
High fever for 3-4 days
Abrupt drop in fever with appearance of rash
A
Roseola infantum- human herpes virus 6,7
22
Q
fussy baby not consolable
A
rule out meningitis
23
Q
Begins distally (erythematous, blanching, fine, maculopapular)**
Spreads centripetally & becomes petechial
Often see conjunctival erythema, edema and photophobia w/ rash
A
Rocky mountain spotted fever
rickettsia
Must treat immediately if suspected
Doxycycline (in all children)
24
Q
Maculopapular rash beginning on the face and spreading to the trunk and extremities***
A
meningococcemia
25
Maculopapular rash beginning on the face and spreading to the trunk and extremities***
meningococcemia
26
what is a full neuro exam
A “top to bottom” approach: the cortex to the brainstem, the cerebellum, the spinal cord, and the peripheral nerves
1. Mental status examination
2. Cranial nerves
3. Cerebellum
4. Strengths
5. Deep tendon reflexes
6. Sensory testing, as needed
7. Gait, if possible
27
what are the components of a mental status exam
Level of consciousness
orientation
language
attention
memory
executive/intellectual function
non-dominant hemisphere
28
difference b/w LOC that is lethargic vs. stuporous
* LETHARGIC: Patient prefers to sleep, but will stay awake with minimal verbal or physical stimulation
* STUPOROUS: Patient requires repeated physical stimulation to stay awake
29
what are some causes of stupor or coma in a pt that was previously alert
something is seriously wrong
* 1. The patient has had a new problem such as a decline in the function of an organ system: CNS, heart, lungs, kidneys, liver
* 2. A new medication has produced an adverse effect
* 3. The bacterial infection has spread to the blood: sepsis
* 4. The patient’s hematocrit, glucose or partial pressure of oxygen has declined, or the partial pressure of carbon dioxide has risen
30
what is included in orientation
person, place , time
* Not always valuable in localizing brain disease, but traditionally tested in virtually all patients
* May be affected by any of the medical conditions that cause delirium or dementia
31
what does aphasia mean
• Aphasia is ALWAYS an indication that the patient’s DOMINANT HEMISPHERE is impaired: stroke, hemorrhage, seizure, or trauma, if it is a sudden result, or a tumor or dementia, if GRADUAL over many months or years
32
difference b/w broca's and wernicke's aphasia
* BROCA’S APHASIA: frontal lobe, usually accompanied by hemiplegia, retained understanding, brief “telegraphic” output
* WERNICKE’S APHASIA: less common, superior temporal lobe, fluent, poor understanding. No weakness
* Both have ANOMIA, or inability to name objects, and inability to repeat
* Both usually have limitations in writing, AGRAPHIA
33
what does dysarthria indicate
• DYSARTHRIA, or slurred or thick speech, may be due to disease of either hemisphere, and sometimes the brainstem, or may be due to a decline in consciousness or medication effect, or diseases of the larynx or mouth
34
what are the steps in testing language function
* First of all, listen to patients, beginning with your history taking
* Have patients REPEAT words or simple phrases
* Have patients READ a paragraph
* Have patients WRITE a sentence
* Have patients carry out two or three step functions you read to them: “Close your eyes, stick out your tongue, and raise your right arm”
* Have patients NAME some simple objects, such as a pen, a comb, a cup, etc.- dollar bill
* Anomia – inability to name simple things
35
what is apraxia and why does it occur
* Partial damage to the dominant lobe, resulting in the loss of complex, multi-step actions, such as combing the hair, brushing the teeth, shaving or putting on makeup, or even getting dressed
* Patients cannot carry out these tasks, even though they have sufficient motor and sensory functions to do them
* Likely due to damage to connections between different sites in the cerebral cortex
* Common in stroke survivors and in severely demented people
36
what is Gerstmann syndrome and what causes it
• Most patients with apraxia have a lesion of the dominant parietal lobe, leading Gerstmann to name a syndrome specifically found from damage to the angular gyrus of the dominant PARIETAL lobe:
* 1. ACALCULIA: Inability to understand numbers or to calculate
* 2. AGRAPHIA: Inability to write
* 3. Inability to distinguish the left and right sides of the patient (or of the examiner)
* 4. Inability to distinguish the individual fingers
37
how do you test attention
Three easy tests for attention (sometimes called concentration)
* 1. Digit repetition, generally 7 forward and 5 backwards
* 2. Serial sevens, subtracting seven starting from 100
* 3. Read a series of letters, asking the patient to raise his hand when he hears the letter “A”
* 4. Have the patient spell “WORLD” forwards and backwards
38
The disoriented patient, who can suddenly no longer give you his location or the approximate date or time…
OR:
The inattentive patient, who cannot stick to the subject at hand, fails to do serial sevens, or cannot spell a word forwards or backwards…
may have...
delirium
• Patients with delirium can not reliably be tested for any parts of the MSE beyond attention, or certainly not beyond language
39
what is delirium
* Now often called ACUTE CONFUSIONAL STATE, or ENCEPHALOPATHY
* There may be agitation (aggressive and dangerous behavior), sometimes hallucinations, tremors, wide fluctuations in blood pressure and pulse rate
* Usually there is hyper-reactivity to environmental stimulation, or at other times, extreme sleepiness
* Suggests in most cases a diffuse systemic problem is affecting large sections of the brain, such as both hemispheres or the entire brainstem
* Often due to serious infections sometimes with sepsis, new medications, impairment of respiration, hepatic or renal function, or a widespread stroke, infection or infections within the brain, or alcohol or narcotic withdrawal
* Localizes to widespread dysfunction of the entire brain
* Patients with delirium can not reliably be tested for any parts of the MSE beyond attention, or certainly not beyond language
* They are too inattentive to understand memory testing, and to recall the words they hear
* Very poor at executive functions, because of lack of concentration, and functions of the nondominant hemisphere
* The physician cannot conclude that a delirious patient has these other MSE abnormalities until the delirium clears
* However, patients with prior dementia are more vulnerable to delirium
40
anterograde
recent memory
recent memory, or the ability to store new information, up to a few days
41
retrograde
distant memory
including autobiographical (dates of graduation, marriage, etc.) or historical (date of wars, elections, sports, etc.). Less commonly lost
test by:
Less often tested, mostly for confirming a diagnosis of dementia
Examples:
• 1. When did you graduate from high school?
• 2. When did you get married?
• 3. How many children do you have?*
• 4. When did you retire?
• 5. When did the Vietnam War (or World War II) occur?
• 6. Can you name some recent presidents?
42
where does memory impairment stem from
• Localizes to BILATERAL medial temporal lobe damage, particularly the HIPPOCAMPUS
43
how do you test anterograde memory
• Testing recent memory: “Please listen to these 3 words, and then repeat them. I will ask you to remember them soon.” Memorize your OWN 3 words, and ask them in approximately 3 – 10 minutes. Some patients deserve a second try.
• Occasionally a normal patient will recall only 2/3, but recalling 0, or 1 words on two attempts is pathologic
Also tested by:
• 1. “How long have you been in the hospital?”
• 2. Giving a patient a brief story to remember, perhaps three or four sentences long
• 3. “What did you have for breakfast (or lunch, dinner)?”
• 4. Hide three objects in your examining room
44
how do you test executive intellectual function
Recent news events, recalling recent Presidents or the current governor of the state, general fund of knowledge (distances, geography), determining similarities of two objects, the interpretation of common proverbs
45
what is verbal fluency
testing of executive function
* 1. Ask the patient to name as many members of a category as he can:
* Examples: animals, girls’ or boys’ names, states in the United States, cities in Colorado, things you can buy in a grocery store or an apartment store, or words beginning with the letter A, F, S, etc.
* Most healthy young patients can name 20 or more in one minute, while demented elderly patients will name less than TWELVE in one minute
46
what does abnormal executive function, judgment and abnormalities in nondominant hemisphere indicate
* These are the indicators of DEMENTIA;
* A more gradual, subtle loss of all of the higher cognitive abilities, which develops over months or years
* Unlike delirium, dementia is usually irreversible
* Patients will lose their memory in most types of dementia, their ability to do the activities of daily life, their social and occupational skills, and ultimately they will be unable to live independently
* As dementias progress over years, the earlier aspects of the mental status exam will also suffer, such as orientation and attention, language, and finally even level of consciousness
47
what is the non dominant hemisphere responsible for
| parietal, temporal, occipital
visual-spatial and construction skills, neglect, music
• Some functions are partly or entirely localized to the right hemisphere:
* Parietal lobe: visual-spatial skills, constructions, awareness of one’s own body or the environment, especially to the left visual field
* Abnormalities suggest a new tumor, stroke or trauma, or part of dementia
* Temporal lobe: loss of musical abilities and a tendency to psychiatric disturbances such as psychosis, depression and bipolar disorder, anxiety
* Occipital lobe: left homonymous hemianopia and prosopagnosia, inability to recognize faces
48
what is • Anosognosia
the inability to recognize weakness in a patient’s left arm or left leg. If you hand the patient your left arm they will think it’s their arm.
49
how can you test a lack of constructional skils
* Again, a sign of nondominant (right) parietal lobe damage
* Can be tested by having the patient draw, or copy, simple and then increasingly complicated figures, such as a circle, a square, a cube, a house, or a clock with all of the numbers
* May also reveal hemispatial neglect
* Very much impaired in dementias such as Alzheimer’s Disease
50
pupil that does not react to light at all
may be caused by blindness, optic neuritis (sometimes due to multiple sclerosis), an optic nerve tumor, or when it is dilated and unreactive, due to Adie’s pupil (polyneuropathy, especially in diabetics)
51
unilateral significantly dilated pupil
• A unilateral significantly dilated pupil may be due to a lesion of CN III, including herniation of the ipsilateral cerebral hemisphere!
52
which types of lesions in the brain spare the pupil
* Occasionally due to strokes, diabetes, or even migraine, when temporary. Basilar artery lesion
* These disorders usually “spare the pupil,” if due to ischemia inside of the midbrain
* The pupil is NOT spared in lesions from outside the midbrain: tumor, herniation of the ipsilateral cerebral hemisphere due to a large tumor or hemorrhage
53
which artery if aneurysm occurs will disrupt CN III
• Also can be caused by a life threatening aneurysm, ruptured or unruptured, of the posterior communicating artery
54
which CN is the only completely crossed cranial nerve
trochlear (CNIV)
serving the contralateral superior oblique muscle, damaged by trauma or congenital disease
55
how do you test trochlear nerve
look down and in
this muscle moves the eye downward and out
56
CN VI
• CN VI, the abducens nerve, serves the ipsilateral lateral rectus muscle, and can indicate localized disease of the pons or the skull, or increased intracranial pressure from tumors or trauma anywhere inside the skull
57
what are the components of CNVII
* Almost entirely motor, to the muscles of facial expression
* But also taste of anterior tongue, lacrimation and salivation
* Limitation of hearing damage from loud noise by contraction of the stapedius muscle
58
peripheral 7th nerve palsy
lesion is in the course of the facial nerve after it has left the pons;
BOTH the upper and the lower facial muscles on that side are impaired: these are peripheral seventh nerve palsies
59
central 7th nerve palsy
; the lesion is in the brain stem in the pons or the midbrain, or far more commonly in the contralateral cerebral hemisphere, and ONLY the lower facial muscles are impaired
60
what is the laterality of cerebellar control
* Mostly important for coordination of movements on the SAME SIDE: this is due to the “double cross” of cerebellar efferents crossing over in the brainstem and going to the contralateral thalamus and contralateral motor cortex; descending corticospinal fibers will cross in the medulla oblongata
* Remember that because of the “double cross,” CEREBELLAR DISEASE IN ONE LOBE ALWAYS PRODUCES ABNORMALITIES ON THE SAME SIDE OF THE BODY
61
how do you test the cerebellum
* Finger to nose, extending the patient’s arms completely
* Rapid alternating movements
* Knee to ankle movements of the opposite leg
• Strokes and hemorrhages, or expanding tumors of one cerebellar hemisphere may cause rapid death due to BRAIN STEM DAMAGE AND BLOCKAGE OF THE FOURTH VENTRICLE’S CSF FLOW
62
what is the romberg test and what is it testing
* Actually, a better test of the POSTERIOR COLUMNS (gracile and cuneate fasciculi) than the cerebellum; best done after other cerebellar tests are completed
* Upright posture requires 3 functions:
* 1. Vision
* 2. Cerebellum
* 3. Posterior columns
63
2/5 strenghth
• 2/5. minimal horizontal movement, but no movement against gravity
64
3/5 strength
• 3/5. Some movement against gravity
65
quadriplegia
• Quadriplegia: disease of the upper or mid cervical spine, or both of the corticospinal tracts of the brain stem
66
hemiplegia
• Hemiplegia: disease of one cerebral hemisphere or one side of the brainstem along the corticospinal tract
67
paraplegia
• Paraplegia: disease of the spinal cord in the thoracic or high lumbar regions
68
DTR's and ratings
All DTRs are traditionally graded 0 – 4
• 0: no reflex
• 1: diminished reflex
• 2: average reflex
• 3. increased reflex, but only one beat
• 4. increased reflex with CLONUS: two or more beats
A reflex of 0 is usually pathologic, but a reflex of 4 is always pathologic
69
what is the babinski sign .... not test
• There is NO Babinski TEST!!!
• There is a plantar reflex, in which the sole of each foot is quickly stroked from the heel to the toes
• The Normal Plantar Reflex is FLEXION of the big toe
• The Abnormal Plantar Reflex is EXTENSION of the big toe, sometimes with separation or “fanning out” of the smaller toes
This Abnormal response, with big toe extension, is called a: BABINSKI SIGN
Indicates UMN lesion
70
upper motor neuron injury
• Increased reflexes, spasticity, only delayed atrophy of muscles, Babinski signs
71
lower motor neuron injury signs
• Decreased reflexes, atrophy within weeks, sometimes fasciculations, no Babinski signs
72
what are some causes of decreased DTR's
• If decreased, may be due to diabetes mellitus, hypothyroidism, vitamin B12 deficiency, exposure to heavy metals or some organic chemicals, increased production of immunoglobulins, auto-immune diseases
73
when should you perform the sensory exam
I recommend it be your final, or next-to-last area in the neurological examination
74
sensory loss seen in cerebral hemisphere damage
numbness of the entire contralateral face, arm or leg
75
what is spastic gait
• Spastic gait: Limited ability to bend at the hips and knees
76
what is spastic gait
• Spastic gait: Limited ability to bend at the hips and knees
77
normal CSF pressure
78
where is the end of the spinal cord
L2
keep taps below this
79
when you want to do a spinal tap, what should you do first
CT
unless meningitis is suspected
80
what causes low spinal fluid pressure
spinal cord tumor
spinal fluid leak
hypo production
81
what causes high spinal fluid pressure
Hyper-production
Proximal to Occlusion
Malabsorption of spinal
fluid
Obesity. Pseudo tumor
cerebri
you will see papilledema
82
xanthochromic csf
Old blood pigments
| Remote bleeding
83
macrophages (monocytes) in CSF?
CHONIC CONDITIONS- brain abscess
84
CSF glucose levels?
CSF GLUCOSE LAGS ONE HOUR BEHIND BLOOD GLUCOSE NEVER
LOWER THAN 80% OF BLOOD GLUCOSE
High spinal fluid glucose may want to check for diabetes
85
protein CSF
86
what is the epidural space
EPIDURAL SPACE IS A POTENTIAL SPACE THAT CONTAINS NO FLUID OR BLOOD ONLY ACCESS
TO THE NERVE ROOTS & DISC MATERIAL
87
does a negative EEG rule out seizure disorder
no
88
what is the use of X-rays in neuro
screen for fx's
when looking at the cervical spine region look at the cervical lines there should be 4
89
uses of non contrast ct
hemorrhage
spinal fx
kidney stone
90
contrast CT
tumor
| abscess
91
what is the use of PET scans
FDG put into pt's
METOBOLISM OF FDG IN THE GLUCOSE PATHWAY GIVES OFF POSITRON + GAMMA RADIATION
CANCER CELLS USE MORE GLUCOSE THAN NORMAL CELLS
AND EMIT MORE
GAMMA RADIATION
92
T1 MRI
RELAXATION
LONGITUDINAL TO
THE MAGNETIC FIELD
93
T2 MRI
RELAXATION
TRANSVERSE
TO THE MAGNETIC
FIELD
94
in T2 images, what is bright
water (CSF)
edema, tumor, infarct, inflammation, infection, subdural collection
gray matter is brighter than white matter
looking for water that is not supposed to be there
95
in T1 what is dark
water (CSF)
edema, tumor, infarct, inflammation, infection, hemorrhage
white matter is brighter than gray matter
96
in T1 what is bright
fat
```
Subacute hemorrhage
Melanin
Protein-rich Fluid
Slowly flowing blood
Gadolinium
Laminar necrosis of an infarct
```
97
what is the FLAIR image
MRI that is T2 weighted with spinal fluid blanked out
edema and gliosis are hyperintense
want to see fluid that is not spinal fluid
98
uses of MRI
MS
Tumor
meningitis (edema/excess fluid)
angiography
soft tissue
NOT AS GOOD AS C.T.
FOR ACUTE STROKE
99
what is the new way to measure intracranial pressure
ultrasound on the eye
100
what is CT best for
acute cerebral bleeding
abcesses
fractures
101
what is CT best for
acute cerebral bleeding
abscesses
fractures
102
what is CT best for
acute cerebral bleeding
abscesses
fractures
103
when do you suspect a nerve injury with a laceration
* 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 hand; comparing findings on the identical site of the uninjured side is the best control.
104
complete tendon vs partial rupture in laceration signs
* 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.
105
which types of wounds are liekly to have foreign bodies
involving glass
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.
106
why don't you use betadine for cleansing a wound
it is for intact skin, so it can cause necrosis on open wounds
107
lidocaine versus bupivacaine
longer acting = bupivicaine 2-4 hours
108
list some absorbable suture material
catgut
polyglactin (vicryl)
poliglecaprone (monocryl)
polglycolic acid (dexon)
109
catgut
* 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. Chromic gut retains tensile strength for 10 to 14 days.
* The main use of chromic gut is 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. It is less optimal for use in dermal (subcutaneous) and muscle layer closures because of increased tissue reactivity.
110
fast absorbing gut
facial lacerations
• Fast-absorbing gut is a newer primarily for epidermal suturing, where sutures are only required for material not treated with chromic salts. It is heat-treated to accelerate tensile strength loss and absorption. It is used five to seven days . The use of this fast-absorbing suture was studied in 654 wounds during plastic surgery procedures. The suture was adequately dissolved in the majority of cases during follow-up visits at four to six days. Fast-absorbing gut is ideal for suturing facial lacerations when tissue adhesives cannot be used or suture removal will be difficult. However, care must be taken to be gentle with tying knots when using the smaller (6-0) fast-absorbing gut, due to its low tensile strength. It is reasonable to reinforce this suture with skin tapes.
111
vicryl
polyglactin
• Polyglactin 910 (Vicryl) — Introduced in 1974, Vicryl 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. Vicryl is an ideal choice for subcutaneous sutures***
112
monocryl
poliglecaprone
• Poliglecaprone 25 (Monocryl) — Monocryl 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 [12].
113
what are some common non absorbable sutures
```
silk
nylon
polypropylene
cotton
stainless stel
```
114
silk sutures
• 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. Body might recognize as foreign body→ inflammatory response
115
nylon
• 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].
116
polypropylene
• 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.
117
pro cons of interrupted
* Easy to learn and do but poor cosmetic result b/c of all the different sutures with different amounts of tensions
* Allows for removal of only some of the sutures in cases of infection
* Better for wounds that are jagged or irregular
* If a suture breaks, the remaining sutures remain in place
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continuous suture
* Also called a baseball stitch
* Closes the wound quickly
* Generally gives a better cosmetic result since tension is spread uniformly along the wound edges
* If the suture breaks the entire wound opens
119
horizontal mattress
• A horizontal mattress suture is usually best for high-tension wounds or wounds with fragile skin. Placed over joints and areas with a lot of motion
120
vertical matress
good for everting
121
in what pt's must you not use dermabond
* Immunosuppressed patients
* Diabetics
dont use in wounds:
• Contaminated
• Complex
• Jagged
• They should also be avoided on mucosal surfaces
and areas that maintain moisture, such as the groin or axillae.
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excisional biopsy
L 3 or 4 times W
30 degree or less angles
123
when do you obtain surgical consult in wounds
• 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
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when do you not close a wound
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wound open >6 hrs
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
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delayed primary closure of a 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, 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.
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face timing of removal
three to five days
127
scalp and arms removal of sutures
7-10 days
128
trunk, legs, hands or feet removal of sutures
10-14 days
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palms or soles suture removal
14-21 days
