Midterm Flashcards
What’s inside a NCNM suture pack?
Forceps, hemostats, scissors, guaze
What are the two types of forceps typically in a NCNM suture pack?
Adson dressing forceps
Brown-Adson tissue forceps - teeth!
What is the difference between the structure and use of needle holders vs. hemostats?
Needle holders have serrated or smooth jaws. Hemostats have a crosshatched surface that will cause the needle to “roll”
What are the typical scalpel sizes, and when are each used?
#15 - small lesions #11 - draining abscesses #10 - large lesions
What are the different types of suture materials?
Nylon (Ethilon), Silk - non-absorbable
Vicryl - absorbable
The more 0000, the thinner the suture (3-0 > 6-0)
3-0 Ethilon is most common at NCNM
What are the basic types of needles used?
Strait suture needles - not used typically, only for very large wounds
Curved needles - #19 is the MC used at NCNM; conventional or reverse cutting
What suture sizes are used in various body areas?
Face/head - 5-0, 6-0, 7-0
General body - 3-0, 4-0, 5-0, 6-0
What are the common needle sizes used for anesthetic injection in minor surgery and applicable locations on the body?
27 gauge - 1” - typical
30 gauge - 1” - for minimal pain/facial lesions
What is considered the most important aspect of sterile technique?
Dawning on sterile gloves
What are the basic antiseptics commonly used?
60-90% alcohols 3% iodine 7.5-10% iodophors (betadine) 2-4% Chlorhexidine gluconate (Hibiclens, Hibiscrub, Hibitane) 0.2-2% Triclosan Hydrogen peroxide
Which is considered the best pre-surgical antiseptic?
Betadine
What are the pros/cons of nonionic surfactants?
Pro - surface active agents with the cleaning properties of soap but virtually no tissue toxicity, including the eye and cornea
Con - No antibacterial activity
Post-operative infection is determined by what risk factors?
Number of microorganisms entering the wound
Type and virulence of the bacteria
Patient vitality
External factors - surgery duration, length of hospital stay, etc.
What are the pros and cons of shaving skin before prepping for surgery?
Pros - visibility and sterility
Cons - shaving causes multiple areas of nicking of the skin which provides a portal of entry for secondary infections
Best to use scissors or clippers
What are the pros and cons of using alcohol for skin prep injections?
Pros - good sterile ability
Cons - no residual antiseptic effect
What are the standard numbers for effective autoclaving?
250 degrees F, at 15lbs/sq. in. for 30min
Informed consent implies that the patient completely understand what issues?
- The nature of the treatment
- All material risks for the treatment
- The possibility of risk
- Alternative treatments available and associated risks
- Consequences of going untreated
What is the meaning of PARQ?
P - procedure
A - alternatives
R - risk
Q - questions
What is the concept of “free margin”?
Free margins indicates that the edges of the biopsy are normal, indicating complete removal of the abnormal tissue
What is the “dead space”?
Deep wounds that, if closed superficially, leaves a space below
Why do you undermine?
It allows the skin to slide over the subcutaneous tissue more easily and stretch enough to close the opening with less tension, resulting in less scarring.
What are the four reasons for/advantages of using the subcutaneous suture? What type of suture would you typically use?
- Provide wound stability
- Close dead space
- Help evert the edges
- Relieve tension on the wound edge
A buried stitch
What are the four most widely used local anesthetic agents used? Which are esters and which are amides? Which is most likely to cause allergies?
Esters: Procaine and Tetracaine (allergies more common)
Amides: Lidocaine and Marcaine
What are the mechanisms of action of local anesthetics?
Prevent or relieve pain by preventing the generation and conduction of nerve impulses - block ion channels
Which nerve fibers are most sensitive to actions of local anesthetics?
Small nerve fibers - pain fibers
What can be added to tetracaine and lidocaine when used for topical anesthesia to produce vasoconstriction?
Epi or cocaine
What are the benefits of adding epinephrine to local anesthetics?
Decreases bleeding, prolongs anesthetic effect, minimizes the amount needed
What are the potential side-effects of local epinephrine injection?
Hypoxic damage in areas with limited circulation - digits, genitals, toes, ears, nose
How quickly will epinephrine in a local anesthetic produce it’s full effect?
5-10min
When applying local anesthetics, which sensations/functions disappear first? What order do they return?
- Sensation of pain
- Temp
- Touch
- Deep pressure
- Motor function
Recover in reverse order
What are some major drug interactions with local anesthetics?
MAO inhibitors –> Hypertensive crisis
Carbamezapine and cyclobenzaprine –> increase effects
Tricyclics and tetracyclics –> hypertensive crisis
Phenothiazines –> profound HTN
What is the most frequent CNS action of local anesthetics?
Sedation
Into which tissues is it not safe to inject local anesthetics containing epinephrine?
Fingers, toes, genitals, ears, and nose
What is the purpose of adding sodium bicarbonate to local anesthetics?
Buffer the acidic solution to a more physiologic pH to reduce pain
Can sodium bicarb be safely added to local anesthetic products containing epinephrine? What are the effects?
Yes, as long as it is immediately before use.
It decreases the overall activity of Epi
Define “infiltration anesthesia”
Injection of a local anesthetic directly into tissue without considering the course of cutaneous nerves
What are the “two” definitions of a field block?
- Injection of a combination of intradermal and subQ local anesthetic solution in an inverted V just proximal to and to each side of the lesion
- Injection of a combination of intradermal and subQ local anesthetic solution completely around the boundaries of the lesion
What are the two advantages of a field block over infiltration anesthesia?
Less drug can be used to provide a greater area of anesthesia and you avoid distorting the anatomy of the lesion for bx
What are the various routes of administration of local anesthetics?
Topical, infiltration, field block, digit or nerve block, IV regional, spinal, epidural
What are the considerations when choosing an infiltration anesthetic?
Side effect profile, hx of pt use, how long the procedure is going to last, pain post-procedure
What are the maximum allowable safe single doses of plain 1% lidocaine and 0.25% bupivacaine alone and with epinephrine?
1% Lidocaine - 4.5mg/kg (30mL average adult)
0.25% Marcaine - 3mg/kg (70mL per average adult)
What alternatives to local anesthesia are available when a patient is apparently allergic to the ones commonly used?
Skin testing - if possible
Use methyl paraben preservative-free if possible. Use the opposite class (ester or amide) or inject with some local benadryl
Vertical mattress sutures: advantages and disadvantages?
Pros - everts edges better than other stitches, helps close large area of dead space in a wound
Cons - time consuming, can scar
What is the difference in onset and duration of cocaine and tetracaine? Maximum dose?
Cocaine - O: 3-5min; D: 30-120min; MD: 200mg
Tetracaine - O: 3-8min; D: 30-60min; MD: 50mg
In what instances do topical anesthesia most likely carry the risk of systemic absorption?
When applied to denuded skin and in infants
What are the present day medical uses of tetracaine drops?
For glaucoma testing and removal of corneal foreign bodies
What are the OTC uses for lidocaine gel/ointment?
Sunburns, insect stings and bites
What is EMLA? Common uses?
Eutectic mix of lidocaine and prilocaine.
Relieve pain of venipuncture/injections, superficial minor surgery, pretx for infiltration anesthesia, skin graft harvesting
How deep does EMLA penetrate? How quickly does it work? Can it be used on mucosal membranes? Precautions?
5mm
1hr
Yes! And genitalia!
Don’t apply near the eyes, on broken or inflamed skin, open wounds, more than 2,000 c. cm.
What are the cutaneous sxs that may occur in anaphylaxis?
Urticaria, pruritus, warmth and redness
What are the early s/sxs of anaphylaxis?
Sensations of warmth or flushing, itching, lightheadedness, sudden fatigue, and a sense of unease
Protocol for treating anaphylaxis?
- Call 911
- Administer Epi 1:1000, 0.3-0.6cc subQ or IM
- Begin with lower dosage and repeat 15-30min
- Administer oxygen at 15L/min
- Administer benadryl 50mg IM
- Monitor for EPI toxicity
- If attack continues, maintain airway, administer second dose of epi and benadryl
- Check vitals - if BP drops, start IV and maintain systolic BP at 90mmHg
- Cardiac arrest - give epi at 1:10,000 10cc IV, followed by 50mg IV benadryl
Concentrations of Epi in an epi pen and epi pen jr?
Epi pen - 0.3ml 1:1000
Epi pen Jr - 0.15ml 1:2000
What flow rate of oxygen is generally considered to be safe in a COPD patient?
at or below 2L/min
What happens if you administer too high of oxygen?
Pain with breathing or coughing and oxygen toxicity.
What are the three functions of a horizontal mattress suture? What are the risks? When should you remove them?
Retention or stay stitch
Helps approximate edges
Helps hemostasis
Removal: at time of surgery as stay suture or a few days after healing has begun
Don’t pull too tightly, can cause hypoxia
