Chapter 9

Question 1

Name the six goals of wound care

Answer 1

reduce ecchymoses
reduce dead space
prevent hematoma and seroma formation
prevent infection
preserve function
preserve appearance

Question 2

What are the seven complications of wound healing

Answer 2

ecchymoses
hematomas
seromas
infection
dehiscence
bad scarring
loss of function

Question 3

What are the causes of ecchymoses?

Answer 3

Blood leaks into the skin, often into the subcutaneous fat.

Question 4

How can we reduce their severity?

Answer 4

Careful handling of tissues during surgery and repair.
Avoid excessive volume of local anesthesia
proper bandaging pressure (tight enough to prevent blood from oozing into tissues, but not to cut off circulation) for 24 hours
ice intermittently for 2-3 days

Question 5

What causes hematomas

Answer 5

post op

sustained capillary bed leakage or venous/arterial bleeding from surgical site or traumatic lesion

Question 6

What pre-operative steps can be taken to reduce the occurrence of hematomas

Answer 6

• assess each patient’s general health status and Hx of coagulopathies
• Identify any Hx of significant bleeding during prior low-risk surgical or dental procedures
• Identify common medical problems (renal dysfunction, hypertension, liver disease, abnormal coagulation, diabetes) which may affect healing
• Screen for alcohol abuse (impairs coagulation of platelets and decreases vasoconstriction
• Identify all medications and last date taken

Question 7

T or F: Asprini, AlkaSeltzer, ibuproven and clopidogrel (PLavix) have been shown to increase risk of hemorrhage more than warfarin

Answer 7

True
Noted to also increase operative and post-op bleeding: GIngko biloba, garlic, ginseng, ginger, feverfew, Vit E, saw palmetto

Question 8

T or F: all prescribed and nonprescribed anticoagulants must be stopped 1 week prior to dermatologic surgery

Answer 8

False
Continue warfarin or clopidogrel (Plavix) to avoid thrombotic events.
Avoid use of cnon-medically necessary supplements and anticoagulants for 1 week

Question 9

What intraoperative steps can be taken to reduce bleeding and hematomas

Answer 9

• Produce careful surgical hemostasis
• Use quilting (figure 8) sutures to tie off bleeders
• Place drains when needed
• Choose Quikclot or surgicel gels: help reduce surgical time, lessen the necessity for drains, overall decrease in operative complications and increased quality of care for patients

Question 10

What post-op management steps can reduce bleeding and hematomas

Answer 10

Pressure bandaging: for 24 hours post-op excisional surgery use hypoallergenic paper tape or elastic wrap (ex. Coban) to hold in place, 2 twice folded 4X4s
Apply ice packs over the dressing for 20 minutes every hour for six hours for patients on anticoagulant meds or excessive bleeders during surgery
COnsider prolonged use of drains and suction drains

Question 11

Contrast the treatments for expanding or clotted hematomas compared to fluctuant ones

Answer 11

Hematoma expanding or clotted:
1)partially or completely re-open the surgical wound
2)identify oozing vessels
3)stop bleeding by suture ligation or electrosurgery
4)full-layer reclosure
5)insert drain if indicated
6)Secondary intention if high risk of more bleeding or wound is contaminated, let heal by secondary intention
Hematoma is a fluctuant (liquified) mass
*aspirate: using large needle directly through the wound
*Reapeat daily until hematoma stops forming
*Continue using pressure bandaging

Question 12

Does prophylaxis with antibiotics for routine or elective MS generally lower the risk of infection?

Answer 12

No. It increases the risk of infection -kills off good microbes too

Question 13

What are the current guidelines for withholding antiplatelet drugs and other anticoagulants

Answer 13

*Delay surgery for three days after the last dose of aspirin
*COntinue warfarin or clopidogrel (Plavix) to avoid thrombotic events.
Avoid use of non-medically necessary supplements and anticoagulants for 1 week
Bottom Line: in each case, weigh the real and increased risk of bleeding with the lower but potentially life-threatening risk of a thrombotic event if an anticoagulant is temporarily discontinued

Question 14

Prophylatctic antibiotics are indicated in patients with traumatic wounds in what three situations

Answer 14

prosthetic cardiac valve
Hx of infective endocarditis
congenital heart disease

Question 15

What are the arguments against using antibiotics in traumatic wounds

Answer 15

• there are limited indications for the routine use of antibiotics in lacerations
• there is a single reliable study showing an advantage to prophylactic oral antibiotic use of penicillin for intraoral wounds.
• Clean, properly debrided early traumatic wounds in patients that are not immune compromised do not require prophylactic antibiotics

Question 16

T or F: wounds cannot dehisce as long as sutures are in place

Answer 16

False

dehiscence can occur with the sutures in place or following removal

Question 17

Name the four things that can typically cause wound dehiscence

Answer 17

1) Too much tension
2) Too little tension
3) Inappropriate suture material
4) Poor tissue quality, leading to tissue failure and poor healing

Question 18

T/F: Both cryotherapy and full-thickness lacerations/incisions/excisions carry a risk of nerve and vascular damage

Answer 18

True

Question 19

T/F: sensation, vascular integrity, active and passive ROM must always be assessed in all traumatic wounds before injection of anesthesia and repair of the wound

Answer 19

True

Question 20

T/F: Whenever the skin is cut or damaged via hyfrecation, radiosurgery, lift and snips, shaves or cryotherapy, the color of the skin returns to normal

Answer 20

False

The color of the skin may never return to normal: there may be hyper/hypo pigmentation

Question 21

Any scar that results from any surgery or traumatic laceration will remain colorless

Answer 21

True

Question 22

Name the six causes of hypertrophic scars and keloids

Answer 22

1) genetics
2) body site (upper chest, back, shoulders)
3) quality of the surgery
4) skin tension (worse with more tension)
5) skin types
6) patient’s health status

Question 23

Contrast the definitions of hypertrophic scarring and a keloid

Answer 23

Hypertrophic scarring: enlargement of the scar within the boundary of the original scar
Keloid: enlargement of the scar beyond the original scar boundry

Question 24

Name two reasons for/advantages of using a Four-Point corner stitch

Answer 24

lacerations

specialty procedures