L13: Skin and Soft tissue Disorders

Question 1

Impaired wound healing risk factors

Answer 1

Infection
Smoking
Malnutrition
Immobilization
Diabetes
Vascular disease
Immunosuppressive therapy

Question 2

Administer Td if it’s been longer than

Answer 2

5 years

Question 3

Microbiology of a bit

Answer 3

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

Question 4

Indications for surgical consult for an animal bite

Answer 4

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

Question 5

Give prophylactic antibiotics for an animal bite if….

Answer 5

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

Question 6

Clean bites wtih

Answer 6

Povidine iodine

Question 7

Most cat bites….

Answer 7

Are provoked and involve upper extremities

Question 8

Most dog bites

Answer 8

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

Question 9

If a cat bite punctures below the periosteum…

Answer 9

osteomyelitis or septic arthritis

Question 10

Human bite pathogens

Answer 10

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

Question 11

2 categories of human bites

Answer 11

1. Occlusive wounds

2. Clench fist or fight bites

Question 12

For a human bite mark you HAVE TO

Answer 12

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

Question 13

Dog bites get

Answer 13

primary closure

Question 14

When to xray a plantar puncture

Answer 14

▪ 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

Question 15

Plantar punctures management

Answer 15

• Closure by secondary intent

* Tetanus

Question 16

Management of Needle Stick Injury:

Answer 16

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

Question 17

Indications for closure of a laceration

Answer 17

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

Question 18

DON’T close these lacerations

Answer 18

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

Question 19

Wound dehiscence means

Answer 19

Rupture along a surgical incision

Question 20

During the exam for wounds, make sure to ______

Answer 20

• Careful neuro exam→ neurovascular or tendon compromise

* Evaluation for concomitant injuries, cosmetic significance

Question 21

Wound classifications (4)

Answer 21

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

Question 22

Wound closure classifications (3)

Answer 22

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

Question 23

Traumatic wounds are classified as

Answer 23

Contaminated

Question 24

Wounds from abscess I+D are classified as

Answer 24

Infected

Question 25

Don't _____ before closing a would

Answer 25

Don’t shave wound→ infection, particles

Question 26

Langer's lines

Answer 26

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

Question 27

When irrigating a wound to decrease infection risk....

Answer 27

Do local anesthesia first

Question 28

Days to remove sutures based on location

Answer 28

``` 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 ```

Question 29

3 absorbable sutures

Answer 29

Vicryl PDS (polydioxanone) Chromic gut

Question 30

2 nonabsorbable sutures

Answer 30

Prolene | Nylon

Question 31

Suturing methods

Answer 31

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

Question 32

Analgesia for a lceration

Answer 32

Acetaminophen, NSAIDs

Question 33

Small, uncomplicated lacerations + antibiotic prophylaxis

Answer 33

Not indicated

Question 34

Risk factors for an infected laceration (get abx?)

Answer 34

* 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

Question 35

Cellulitis ISN'T

Answer 35

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

Question 36

Immunocompetent cellullitis microbiology

Answer 36

Group A strep | Staph aureus

Question 37

Immunocompromised cellulitis microbiology

Answer 37

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

Question 38

4 cardinal signs of infection

Answer 38

* Erythema * Pain * Swelling * Warmth

Question 39

Signs of severe cellulitis infection that needs and emergent surgical evaluation

Answer 39

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

Question 40

The most important step to decreasing infection risk of a laceration

Answer 40

Irrigation | debridement and removing foreign body are 2nd

Question 41

Recheck ________ laceration wounds in 48-72 hours

Answer 41

highly contaminated

Question 42

In whom is absorbable suture preferred?

Answer 42

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

Question 43

Which types of cellulitis get admitted?

Answer 43

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

Question 44

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

Answer 44

Mild, local symptoms without evidence of systemic disease Limb elevation to reduce swelling Empiric antibiotics Follow up with in 48-72 hours

Question 45

Abx for cellulitis

Answer 45

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

Question 46

Abscesses with increased risk

Answer 46

Staphylococcus aureus carrier Break in skin Immunocompromised

Question 47

Abscesses that need to be referred to surgery for drainage

Answer 47

``` ▪ 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 ```

Question 48

At home abscess care

Answer 48

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

Question 49

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

Answer 49

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

Question 50

Pathogen which most commonly infects burns

Answer 50

Staph aureus

Question 51

Clinical features of a burn wound infection

Answer 51

Rapid change in condition: | Fever, increased pain, feeding intolerance

Question 52

Managing a burn wound infection

Answer 52

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

Question 53

Managing a burn wound cellulitis

Answer 53

IV Cefazolin or Clindamycin or Vancomycin (MRSA)

Question 54

Pathogens that cause necrotizing fasciitis

Answer 54

Polymicrobial → aerobic and anaerobic Monomicrobial→ GAS or beta-hemolytic strep

Question 55

Organisms which cause Fournier's gangrene

Answer 55

E.Coli, Klebsiella, Enterococci Anaerobes: Bacteroides, Fusobacterium, Clostridium