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Unit 3 Emerg/Surg > L13: Skin and Soft tissue Disorders > Flashcards

L13: Skin and Soft tissue Disorders Flashcards

1
Q

Impaired wound healing risk factors

A 
Infection
Smoking
Malnutrition
Immobilization
Diabetes
Vascular disease
Immunosuppressive therapy
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2
Q

Administer Td if it’s been longer than

A

5 years

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3
Q

Microbiology of a bit

A

oral flora of animal + human skin: Pasteurella (Dogs 50%, Cats 75%)
• Staphylococcus, Streptococci
• Anaerobes (bacteroides & fusobacterium)

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4
Q

Indications for surgical consult for an animal bite

A
  1. Deep penetrating wounds to the bones, tendons, joints or other major structures
  2. Complex facial lacerations
  3. Wounds associated with neurovascular
    compromise
  4. Wounds with complex infections
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5
Q

Give prophylactic antibiotics for an animal bite if….

A

Deep puncture wounds

Moderate to severe wounds with associated crush injury

Underlying venous and or lymphatic compromise

Wounds on hands, genitalia, face or in close contact with bone/joint

Wounds requiring closure

Compromised hosts

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6
Q

Clean bites wtih

A

Povidine iodine

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7
Q

Most cat bites….

A

Are provoked and involve upper extremities

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8
Q

Most dog bites

A

Are a dog known to the human and are head/neck bites

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9
Q

If a cat bite punctures below the periosteum…

A

osteomyelitis or septic arthritis

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10
Q

Human bite pathogens

A
  • Eikenella Corrodens (G- anaerobe)
  • Group A streptococcus
  • Staphylococcus
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11
Q

2 categories of human bites

A
  1. Occlusive wounds

2. Clench fist or fight bites

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12
Q

For a human bite mark you HAVE TO

A

Measure bite marks→ Maxillary intercanine distance >2.5 cm→ adult bite

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13
Q

Dog bites get

A

primary closure

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14
Q

When to xray a plantar puncture

A

▪ Inability to completely visualize interior of wound
▪ Deep wounds caused by glass
▪ Patient believes there is a retained object
▪ Object is small, breakable, or brittle
▪ Object can be seen or felt beneath skin surface
▪ Severe wound pain
▪ Persistent localized pain over wound
▪ Painful mass or discoloration under skin
▪ Missing portion of the object
▪ Injury went through rubber shoe

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15
Q

Plantar punctures management

A
  • Closure by secondary intent

* Tetanus

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16
Q

Management of Needle Stick Injury:

A

Immediately cleanse the exposed site→ soap and water, also alcohol
Report incidence
Documentation
Determine HIV status of source and person with stick injury
Hep B and Hep C
Post exposure prophylaxis
Prevention of spread

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17
Q

Indications for closure of a laceration

A 
▪ Extension into sub Q
▪ Decrease healing time
▪ Reduce likelihood of infection
▪ Decrease scar formation
▪ Repair loss of structure or function
▪ Improve cosmesis
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18
Q

DON’T close these lacerations

A 
Contaminated wounds
Wounds greater than 12 hours old
Presence of Foreign Body
Wounds involving:
tendons, nerves, arteries
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19
Q

Wound dehiscence means

A

Rupture along a surgical incision

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20
Q

During the exam for wounds, make sure to ______

A
  • Careful neuro exam→ neurovascular or tendon compromise

* Evaluation for concomitant injuries, cosmetic significance

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21
Q

Wound classifications (4)

A

Clean
Surgical incisions
No involvement of GU, GI, respiratory tracts

Clean-Contaminated
Involvement of GU, GI, respiratory tracts

Contaminated
Gross spillage into surgical wound (bile, stool)
Traumatic wounds

Infected
Established infection (I+D abscess)
Gross contamination

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22
Q

Wound closure classifications (3)

A

Primary Intention
• All layers closed
• Best chance for minimal scarring
• Clean/clean-contaminated wounds

Secondary Intention
• Deep layers closed
• Superficial layers left to granulate
• Can leave wide scar
• Requires frequent wound care

Delayed Primary Intention
• Deep layers closed primarily
• Superficial layers closed in 4-5 days after infection is not a concern

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23
Q

Traumatic wounds are classified as

A

Contaminated

24
Q

Wounds from abscess I+D are classified as

A

Infected

25
Q

Don’t _____ before closing a would

A

Don’t shave wound→ infection, particles

26
Q

Langer’s lines

A

Skin tension lines→ run horizontal
Indicate orientation of collagen fibers
Lacerations that run at right
angles to lines (vertical) tend to gape

27
Q

When irrigating a wound to decrease infection risk….

A

Do local anesthesia first

28
Q

Days to remove sutures based on location

A 
Ear→ 4-5 days
Face→ 5 days
Arm/Leg→ 7/8 to 10 days
Scalp→ 7-14 days
Hand→ 8-10 days
Chest/abdomen→ 8-10 days
Fingertip→ 10-12 days
Back→ 12-14 days
Foot→ 12-14 days
29
Q

3 absorbable sutures

A

Vicryl
PDS (polydioxanone)
Chromic gut

30
Q

2 nonabsorbable sutures

A

Prolene

Nylon

31
Q

Suturing methods

A

Simple Interrupted
• 3-10mm in length and same distance apart
• Frequently used to close skin lacs

Vertical Mattress→ in plane perpendicular to skin
• Useful for deep wounds, helps eliminate dead space

Horizontal Mattress→ in plane parallel to skin
• Useful in flaps or wounds under tension

Continuous→ quick, +/- locked→ tighter closure

Subcuticular→ Used often for surgical or clean wounds, must use absorbable suture

32
Q

Analgesia for a lceration

A

Acetaminophen, NSAIDs

33
Q

Small, uncomplicated lacerations + antibiotic prophylaxis

A

Not indicated

34
Q

Risk factors for an infected laceration (get abx?)

A
  • Wound >12 hrs old, especially on hands
  • Bites
  • Crush wounds
  • Contaminated wounds
  • Avascular areas (i.e. ear)
  • Wounds involving joint spaces, tendon, or bone
  • History of valvular heart disease
  • Immunocompromised patients
35
Q

Cellulitis ISN’T

A

NOT:
necrotizing
doesn’t involve fascia or muscle
no abscess, drainage, or ulceration

36
Q

Immunocompetent cellullitis microbiology

A

Group A strep

Staph aureus

37
Q

Immunocompromised cellulitis microbiology

A

Immunocompromised→ nontraditional organisms→ Pseudomonas, Proteus, Serratia, Enterobacter, Citrobacter

38
Q

4 cardinal signs of infection

A
  • Erythema
  • Pain
  • Swelling
  • Warmth
39
Q

Signs of severe cellulitis infection that needs and emergent surgical evaluation

A 
Deep soft-tissue infection:
• Violaceous bullae
• Cutaneous hemorrhage
• Skin sloughing
• Skin anesthesia
• Rapid progression
• Gas in tissue
40
Q

The most important step to decreasing infection risk of a laceration

A

Irrigation

debridement and removing foreign body are 2nd

41
Q

Recheck ________ laceration wounds in 48-72 hours

A

highly contaminated

42
Q

In whom is absorbable suture preferred?

A

Peds and elderly
adhesives not an option (ex: oral mucosa)
Under splints or casts.

43
Q

Which types of cellulitis get admitted?

A

Facial cellulitis of odontogenic origin
Immunocompromised patients
Orbital cellulitis
Cellulitis affecting more than 1⁄4 of an extremity

Patient with comorbidities:
• Lymphedema
• Cardiac, hepatic, or renal failure

44
Q

Which types of cellulitis can be treated outpatient? What’s the treatment?

A

Mild, local symptoms without evidence of systemic disease

Limb elevation to reduce
swelling
Empiric antibiotics
Follow up with in 48-72 hours

45
Q

Abx for cellulitis

A

Cellulitis (Non-purulent)
• Strep most likely pathogen
• Duration of treatment 5 days

MILD infection: Penicillin, Cephalosporin,
Dicloxacillin or Clindamycin

MODERATE infection: Penicillin,
Ceftriaxone, Cefazolin, or Clindamycin

Recurrent cellulitis→ 3-4 episodes per year
• Due to venous or lymphatic obstruction
• Penicillin or Erythromycin BID for 4-52 weeks

46
Q

Abscesses with increased risk

A

Staphylococcus aureus carrier

Break in skin

Immunocompromised

47
Q

Abscesses that need to be referred to surgery for drainage

A 
▪ Perirectal abscesses
▪ Anterior and lateral neck abscesses
▪ Hand abscesses
▪ Abscesses adjacent to vital nerves or blood vessels
→ Facial nerve
→ Carotid artery
→ Femoral artery
▪ Breast abscesses near areola and nipple
48
Q

At home abscess care

A

Follow up in 24-48 hours

Change packing every 24 hours→ +/- as long as 7 days

Wash in shower with soap and water

Recurrent infections→ Bath with chlorhexidine daily

49
Q

MRSA can cause recurrent abscesses, likely due to colonization to get rid of it:

A

▪ Consider 5 day decolonization regimen
▪ BID nasal mupirocin
▪ Daily chlorhexidine washes
▪ Daily decontamination of personal items (towels, sheets)

50
Q

Pathogen which most commonly infects burns

A

Staph aureus

51
Q

Clinical features of a burn wound infection

A

Rapid change in condition:

Fever, increased pain, feeding intolerance

52
Q

Managing a burn wound infection

A
  • Avoid hypothermia in all burn patients
  • Culture
  • Systemic antibiotics with sepsis or septic shock
  • Piperacillin/tazobactam or Carbapenem
  • +/- Vancomycin with suspected MRSA
53
Q

Managing a burn wound cellulitis

A

IV Cefazolin or Clindamycin or Vancomycin (MRSA)

54
Q

Pathogens that cause necrotizing fasciitis

A

Polymicrobial → aerobic and anaerobic

Monomicrobial→ GAS or beta-hemolytic strep

55
Q

Organisms which cause Fournier’s gangrene

A

E.Coli, Klebsiella, Enterococci

Anaerobes: Bacteroides, Fusobacterium, Clostridium

Unit 3 Emerg/Surg (5 decks)

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