Final Exam Flashcards
Why Biopsy
To obtain a sample for histopathology, electron microscopy, or immunofluroescene testing. To obtain a deep culture and to avoid superficial contamination of wounds, to perform an excision for curative or cosmetic purposes.
What if you think it could be melanoma
Full thickness biopsy (punch, incision, or excision) is indicated
CI to Biopsy
Infection, inflammation, traumatized, coagulopathy.
What to use if suture is indicated
Chlorhexidine/Betadine
What do hemostatic agents do?
Control bleeding. Use if not stapling or glueing.
When to use non disposable curettages?
When cancer is suspected. Allows you to feel good and bad tissue.
Disposable curettages
Very sharp. Not when cancer is suspected.
What does a radio frequency unit do?
Cauterizes
If you have a choice of lesion
Avoid cosmetically important areas, avoid old lesions, avoid ulcers, avoid areas with poor circulation, Do not include normal tissue unless a vesicular-bulbous lesion.
Preparing for Punch Biopsy
Obtain a full thickness cylindrical specimen. Select size of punch. Prepare site with alcohol. Re-prep with butadiene or chlorohexidine if sutures will be placed.
Performing a Punch Biopsy
Place a ring of anesthesia around the lesion or deep to the lesion.
How to stretch the biopsy site for a punch biopsy
Perpendicular to the line of tension.
Punch Biopsy Dressings
AB ointment, gauze, band-aid, pressure.
Curettage Biopsy are what kind of biopsy
Partial thickness biopsies
When to use Curettage Biopsy
Basal cell carcinoma Hyperkeratotic epidermal lesions
Curettage Technique
Prepare site with alcohol, use an anesthetic wheel, use the curette to scrape away or scoop out a lesion, Send curetted tissue to pathology if desired, Continue until only normal tissue remains.
When using curettage on carcinomas
They scrap out easily. Repeat the sequence 3 times.
Shave Biopsy
Partial thickness biopsy used to remove a portion of raised skin. Install local anesthetic under lesion.
How to stop bleeding with shave biopsy
Monsel’s can be used if bleeding dried first.
Excisional Biopsy
Full thickness.
Excision
Removes entire lesion
Incision
Removes partial lesion
Excisional Biopsy Technique
use sterile technique. Establish field block anesthesia. Outline planned margins. Butadine prep. Drape.
Undermining
Cloning in at 15 degrees toward the lesion.
When to use primary closure
Wounds less than 24 hours old.
Delayed closure
If wound greater than 24 hours old. Cleanse, insert small piece of petroleum gaze, rx for cephalexin X5 days. Day 3 patient returns, wound reirrigated, closure with non-absorbable sutures.
How to close very contaminated or infected wounds
Leave them to heal on their own. Scarring may occur.
Choice of closure
Sutures, tapes & strips, tissue adhesives
Simple interrupted
Easy to perform. Some can be removed early for better comes, some can be left on later.
Vertical Mattress
Good for elderly people with thin skin where the tendency of wound edges would be to invert and sutures may pull through
Subcutical running
Good for linear wound not under much tension. Avoid pressure on wound as tear easy
Horizontal Matress
Good for gaping wounds especially on fragile skin.
Days to remove stitches on face
3-5 days
Cutting Needle
Ideal for suturing skin. Usually referred now to a “reversed cutting” design.
Swagger eye needle
Needle is molded around the thread. No threading is required.
Needle used on face
P3
With Simple Interrupted stitch needle enters at
90 degrees
Describe simple interrupted stitch.
As wide as it is deep. Equidistance from edges and equal depth on each side. Distance between stitches half the distance of the entire suture: min=2 mm. Knots line up on one side. Edges evert.
Vertical Mattress stitch
wide wide, narrow narrow. Suture ends finish on the same side.
Subcuticular running stitch
Ends can be knotted, taped, or tied.
Suture Tying
First throw should just approximate the edges, subsequent throws are for knot security, apply equal tension on both strands, tension is applied parallel to the loop being closed and along the axis of the knot being tightened. Number of throws beyond the initial square: 4 if monofilament (more slippage) and 3 if braided (more friction) Leave 3-4 mm tails at completion
Suture dressing
AB ointment with low adherent. Gentle wound washing after 12-24 hours or tegaderm over dressing (allows showering)
Tapes and Strips
Used with benzoin or mastisol. Most often used as reinformatment to sutures or staples and sometimes glue. Does not provide skin edge eversion. May also use after suture removal.
Tissue Adhesives
Cyanoacrylates with formaldehyde. Nonmucosal lacerations or incisions. Facial, snap. Wound less than 8 cm (gap less than .5 cm). Do not use in noncompliant patients. Patient may shower after 24 hours. Strips will fall off naturally.
Pros of tissue adhesives
Fast, less painful, no suture removal, low cost
Cons of tissue adhesives
Takes 7 days to reach maximum strength, inadvertent spillage, single use, early dehiscence.
Emergency anaphylaxis
If immediate put a tourniquet over the site. Administer .3 ml of epi. and 25-50 mg of oral benadryl. (chew). Oxygen if prn. Initiate CPR if prn.
Junior epipen
Green. .15 ml
What to check on epipen
Date and contents
What does epic cause
Vasoconstriction and decreased blood flow
Describe how to do the epipen
Hold with black/orange tip down, remove activation cap just prior to use. Hold near outer thigh and 90 degree angle. Hold the device for several seconds (10 s). Remove the device and massage. About 90% of the solution will still be in the pen but cannot reuse.
After give an epipen
Monitor BP, pulse, respiration.
When might you need a second dose of epipen
15 minutes
Who to release patient to after epipen
Only medical personal.
SE of Epinephrine
Tachycardia, arrhythmia, angina, increase BP, sweating, tremor, dizziness, HA, nervous, nausea and vomiting, weakness, apprehension, respiratory difficulty. (THAN AIN STD WAR)
How to confirm the right patient
2 methods.
What should you know about your patient prior to injections
Medical and allergy history
What to do with medications before injections
check it. Make sure it is correct meds, injectable, not exited, and it is as it should.
Anesthetizes of the site
Be smart about it. Can deaden a root and only do one injection.
PARQ
Purpose and nature of procedure, Alternate procedure, Risk and consequences, Questions and answers.
What to do with multi-use meds
discard 28 days later.
Do you recap the needle before putting it in the sharps?
NO
What to document after an injection
Date and time, drug name, concentration, manufacturer, lot number, amount given. Delivery method when administered. (What, Where, When)
What is normally injected IM
AB, epinephrine, Diphenhydramine, promethazine, prochlorperazine, vaccines. (DAVE PP)
What is normally injected IV
NAFL and ICG for angiography, hyperosmatics, verteporfine, edrophonimum) (HVE NI)
What to do IM injections
poor compliance, need quick absorption, doesn’t come in oral, can’t take orally, not effective oral.
IM injection sites
Deltoid (do top of shoulder and 1 hand down), thigh, or hip (don’t use)
Risks and concent of IM
Bruising, tenderness 24-48 hours, tingling due to n. damage, infection
Risk and consent of IM meds
Inflammation and soreness, allergic reaction, anaphylaxis, medication specific.
Needle specifics for IM
1-3 ml syringe, 23-25 gauge needle for injection, 1-1.5 inches long.
Administering IM
Stabilize by pinching with non dominant hand, insert the needle at 90 degrees, release pressure and use non dominant hand to pull back on plunger. Insert medications at a slow pace.
After IM
Massage with cotton ball.
SubQ
Pinch skin and insert at 45. Do not massage. Common sites: Arm, Stomach, thigh
Needle for SubQ
1-3 ml syring, 23-35 gauge, 5/8 inch standard length.
Most common sites for FA injection
Hand and ancubital fossa.
What direction can you do with IV injection
Can go from ancubital to hand but not vice versa.
IV meds SE
Allergic reaction, anaphylaxis, extravasation, N&V
What to use for FA
3 ml of 25% NaFL.
Needle for IV
Bevel up. 90 degree between finger and needle.
Insertion for IV
Begin at 30-45 degrees. If deeper use 45. Flatten once you loose resistance.
Procedure for IV
Put needle in, flatten, Pull black and remove tourniquets, insert blood and look for extravasation, Put cotton ball over injection site and pull out, Pressure once it is out.
When to do ocular Subcutaneous injections
Anesthetic for lid lesion removal. Corticosteroids for chalazion
When to do subconj. injections
Corticosteroid or AB
Anesthetic for subcutaneous
Inject in the lid. Prefer lid but can do palpebral too.
Risk with subcutaneous lid injection
tenderness 24-48 hours, lid perforation, pain on injection, hemorrhage/bruisng
Equipment for subcutaneous injection
3 cc syringe, 5/8 to 1 inch needle.
Anesthetic for subcutaneous inj.
Lidocaine 2% w/w/0 epinephrine 1/100,000 or 1/20000. and/or bupivacaine .5%.
Subcutaneous specifics for injection
Bevel up. 15 degrees. Apply firm pressure with cotton ball once needle is out.
Intralesional injection needle specifics
1-3 cc syringe, 25-27 gauge for steroid.
Why subconj injection
Allows medications to slowly be absorbed into the eye and systemic by scleral and episclera vessels
When are subconj injections commonly used
recalcitrant uveitis and corneal ulcers
Risks from subconj injection
Subconj. heme, ocular tenderness and photosensitivity 24-48 hours, blurred vision and corneal staining, mitosis from briminodine, pain on rotation, dryness and FB sensation, globe performation
Equipment for subconj.
1-3 cc syringe, 27g X 1 inch needle.
Subconj. procedure
Put 1 drop .15% briminodine in eye 30 minutes prior, place 1 drop proparicane OU, Place 1 drop proparicane in eye just about to be treated. Go in with bevel up and tangential to globe.
Normal steroid injection
5-10 mm form limbus. Go in at 2, 4, 8, 10.
If doing a procedure and possible what should you have patient discontinue
Aspirin for 7 days.
Common topical anesthetics used in OD
lidocaine with epinephrine. Good for 30 minutes.
Why use epinephrine with lidocaine?
Decreases bleeding, takes longer to work than lidocaine, prolongs anesthetic affect. Do not use with terminal circulation.
SE of lidocaine and epinephrine
Pain on injection due to low pH. Allergic run, anaphylaxis, Depress all neurologic tissue (CNS toxicity: restlessness, lightheadedness, tinnitus, dizziness, tremors, seizures Peripheral toxicity: tingle in toes). Cardiovascular depression and hypotension. (RTLTDS)
Best time to treat chalazian with steroids
Recent onset. Within 8 weeks.
Common steroid in OD
Methylprednisolone acetate 40mg/ml. Inject .15 ml on average.
Side effects of methylprednisolone acetate
Tenderness, infection, glaucoma, subconj, heme, cataract formation, ONA, tissue necrosis, EOM fibrosis, CRAO.
After chalazian procedure
Topical AB or AB steroid used and cool compress. Recheck in 7-14 days. Repeat if still there
When to not do subconj injection of steroid
Scleritis. Scleral thinning and perforation are consequences.
Steroid subconj injection repeatable?
May need repeat in 2-3 weeks.
SE of subconj steroid
Increased IOP, cataract formation, optic nerve atrophy, tissue necrosis, EOM fibrosis, CRAO, corneal staining.
Meds for subconj. steroid
Methylprednisolone acetate 40 mg/ml. Inject 1-2 ml in 2 or 4 sites
Sodium flouroscene vs Indocyanine green
Sodium fluorescente (retinal vasculature), IG (choroidal vasculature). Both metabolized by liver. NaFL excreted by kidneys and IG by bile. Both are category C and avoided with pregnancy.
Amount of NaFL
3 cc of 25% NaFL as a bolus in the vein
Amount of ICG
40 mg in 2 ml of aqueous solvent as a bolus followed by 5 ml of normal saline.
SE of NaFL or ICG to warn pt. about.
Yellow tint to skin, sclera, urine (always with NaFl), soreness at site, bleeding at site, discomfort at sit, itching, urticaria (hives)
Mild SE of NaFl or ICG
Nausea 20-30 s after injection and resolves in 2-3 minutes. Vomiting (in young and thin). Flushing, dizziness, HA, itching, strong taste.
Moderate SE of NaFL or ICG
Extravasation (tissue damage due to high pH of NaFL), urticaria, syncope, thrombophlebitis at injection site.
Severe SE of NaFL or ICG
Anaphylactoid rxn: urticaria, hives, itching, swelling of lips, tongue throat, bronchospasm, loss of consciousness, cardiac arrest, tonic clonic seizures, death.
High risk for NaFL SE
Previous responders. patients with allergies/asthma. Renal insufficiency.
High risk for ICG SE
Its with allergy to iodine or shellfish. Contains 5% sodium iodine. Renal insufficiency.
Use of IV with large IOP in ACG
Most will start with topical or oral meds. If not working use acetazolamide, mannitol, urea (hyperosmotics). Others will just use IV acetazolamide first.
Tetanus shot
Can use in anyone above 7 years. Shake well as it is a suspension.
SE of Tetansus shot
Inflammation and soreness, syncope, allergic reaction, anaphylaxis, Guillain-Barre Syndrome (inflamed roots of n).
