I&D, Subungual Hematomas, Ticks, Etc. Flashcards
What is essential if hands are contaminated?
Hand washing
What is sufficient if hands are NOT contaminated?
Alcohol based sanitizer
When is alcohol based sanitizer sufficient to clean hands?
When hands are NOT contaminated
What do alcohol based sanitizers not cover?
C. diff or Vanco-resistant enterococcal infections
Define abscess
A swollen area within the body tissue containing an accumulation of pus that is not resolving spontaneously
Community MRSA tends to have more ____ involvement
Cutaneous
Healthcare MRSA tends to have ____ involvement
Bloodstream, PNA, surgical site
MC causes of abscesses
Foreign bodies
Puncture wounds
Who is at most risk of MRSA?
- IVDA
- Poor dental hygiene
- Contact sports
- Incarceration
- Communities w/high prevalence
MC pathogens of abscesses
- MRSA
- MSSA
- Streptococcus
- Other
What types of patients offer a damaging agent easier access to form an abscess?
- Skin of obese, debilitated, elderly
- Diabetics (elevated glycemic state)
- Immunocompromised
Where do abscesses arise from?
Dermal layer and spread lower (to SC fat, muscle and deeper structures)
What is the point/head of an abscess?
Thinnest area
PE findings of an abscess
- Pain
- Edema
- Induration
- Fluctuance
- Surrounding cellulitis
Contraindications to I&D
- Furuncles on face
- Rectal or genital abscesses
When does an abscess warrant caution?
- Abscess from IVDA (“shooters abscess”)
- Purple bluish appearing induration (suggests vascular)
- If a known close proximity to major vessel
- Breast abscess (non lactating female) NOT in subareolar area is rare and should be investigated further
What areas are close to major vessels and should warrant caution for an abscess I&D?
- Peritonsillar/retropharyngeal
- Anterior triangle of neck
- Supraclavicular fossa
- Deep axilla
- Antecubital space
- Groin
- Popliteal fossa
Treatment of simple/small abscess
- Warm compress to allow spontaneous drainage
- Abx NOT necessary once draining
- If it enlarges, it can encapsulate which will render abx ineffective
- I&D, wound culture
When are abx warranted after I&D?
If local cellulitis present
Where should you incise during an I&D?
Along Langer lines
What should an I&D abscess be packed with?
Iodoform gauze
Healing of an I&D abscess progresses in what way?
Inside out - so pack it well and full enough
If abscess needs longer time to heal, what can be done during I&D?
Use criss cross (cruciate) incision
Aftercare of an abscess I&D
- Pain control
- Schedule FU
- Apply warm wet compresses
- Non adherent bulky dressing w/daily changes
- Immobilize cellulitis
- RICE
- Abx are guided by wound cultures and risks
- Refer to surgeon when appropriate
Common site of ingrown toenail
Medial or lateral great nails
MC cause of ingrown toenail
Improper fitting shoes or trimming of nails
Relative contraindications of treating ingrown toenail
- Bleeding issues
- CAINE allergies
- PVD
- Pregnancy (phenol to ablate matrix is contraindicated)
What is onychogryposis?
Congenital curved toenail causing increased risk of ingrown toenail
Complications of ingrown toenail
- Infection
- Nail will regrow if not ablated properly using cautery or 10% phenol
Follow up care of ingrown toenail
- Elevation 24-36 hrs w/gradual return to walking
- OTC pain control
- Dressing changes in 24 hrs
- Soak toe in warm water twice daily for several days after first dressing change
What may occur if pressure of a subungual hematoma is not relieved?
Damage to nail matrix and germinal layer
Contraindications to subungual hematoma drainage
- Crushed or fractured nails
- Tuft fracture
- Suspicious lesion under nail
- Pt wearing acrylic nails
- Over 50% of nail could indicate nail bed laceration (controversy over whether to remove or not)
Complications of subungual hematoma
- Nail deformity
- Infection
- Cautery can cause burn to nail bed (if not used properly)
- Numbness (RARE)
How to grasp tick during removal?
- Grasp at skin level tugging up steadily
- DO NOT TWIST
- Do not grab tick by body or could expel the contents into patient
What of the tick will transmit disease?
Head NOT mandible - if the mandible is imbedded it can stay in, it won’t transmit disease
Treatment for early Lyme disease
Doxy
How should a fish hook wound be prepped for removal?
- Cleanse hook and puncture wound with povidone-iodine or another abx solution
- Provide tetanus prophylaxis as needed
How should superficial fish hook removal be attempted?
“Retrograde” technique - push hook back along entrance while applying gentle downward pressure on shank
How should a fish hook be removed if it cannot be taken out using retrograde technique?
18 gauge needle inserted into puncture hole and used as a mini scalpel blade - manipulate hook into a position so you can cut the bands of connective tissue caught over barb and release it
How should deeply imbedded fish hooks be removed?
- “Needling” the hook
- # 18 or 20 hypodermic needle through wound alongside hook
- Blindly slide needle opening over barb of hook and lock 2 together
- With barb covered, remove hook and needle as 1 unit
What does “needling” a fish hook for removal require?
Greater skill but allows you to work on an unstable skin surface like finger or ear
When unable to try other techniques including “needling”, how can fish hooks be removed?
“Push through” maneuver - then cut off tip of hook and remove shaft
How to remove a multifaceted (treble) hook?
Cover free hooks with corks or use a pin cutter to remove free hooks
DON’Ts of fish hook removal
- Do not try to remove multifaceted hook w/o first covering free hooks or removing them
- Do not attempt “string” technique if hook is near patient’s eye
- Do not routinely prescribe proph abx (infection is rare)
Prophylactic abx for fish hook removal?
Do NOT routinely prescribe - even hooks contaminated by fish rarely cause secondary infection
