Midterm Review Flashcards
Primary intention healing
Healing of wound edges in direct contact
Secondary intention healing
Non-closure of a wound
Very dirty or infected wounds
Animal bites to hands, feet
Tertiary intent healing
AKA delayed closure
Refers to closure of a wound after observation (~ 3-5 days)
What is the best thing to do to prepare the wound?
Thorough irrigation before closure
Pulsing works best
Preparing the wound- irrigation
Remove all visible debris and devitalized tissue
Wounds not in delicate or friable tissue should be scrubbed
-Do not scrub tongue or mouth
Inspect wound to base
-Anesthetize first
-Look for FBs, tendon and muscle injuries
Reusing open bottles of saline for wound irrigation
No, common route of cross-contamination between pts
Components of nylon
Mono filament Time required for absorption: NA Color: black Common use: General Advantages: More secure knots
Components of polypropylene
Mono filament Time required for absorption: NA Color: Blue Common use: General Advantages: strength
Components of polyglactin
Multi filament Time required for absorption: 60-90 days Color: White Common use: Buried, lower layer in layered closure Advantages: Dissolves slowly
Components of chromic gut
Mono filament Time required for absorption: 15-60 days Color: tan Common use: tongue Advantages: dssolves more slowly
What size suture should be used for what part of the body?
3-0 for trunk
4-0 for extremities
5-0 for digits
6-0 for face
General suture placement rules
Introduce the suture needle into the skin at a 90-degree angle
Suture depth should be just above bottom of wound and should be at least as wide as it is deep
VERY IMPORTANT to enter dermis at the same level as where you exited the other side of the wound
Simple running
Faster, but harder to get tight and comes unraveled if any loop breaks
Vertical mattress stitch
Provides layered closure with one stitch
Creates everted wound edges
Good for wound over a joint
Horizontal mattress stitch
Good for high tension wounds or wounds that need to hold most of the tension on one side
Subcuticular stitch
Can do interrupted or running Avoids "train track" or scar appearance Used for surgical or very clean wounds Sutures are placed upside-down to bury knots Final tail is hidden
Special considerations in wound care
Shaving traumatizes skin and contaminates wound
NEVER shave an eyebrow
Take special care to align all natural (and unnatural landmarks)
Try to make any incision along natural skin tension lines
Excessively dirty wounds need recheck
Reasons to use staples for wound care
Easy to use and very quick Can often be placed without anesthesia Don't require sterile technique Don't have to wrestle with tying Automatically evert wound However, leave scars
Tissue adhesive for wound care
Very quick, no anesthesia or sterile technique required
Be very judicious about where and how you use it
Wound must be clean/dry
NO ACTIVE BLEEDING
May pull off sooner in an area with a lot of tension
Mostly just use for forehead and around the eyes, volar part of the arm
Wound tape
Rarely used for primary wound closure
More effective for reinforcing
Sometimes used to re-approximate skin tears
Often used in conjunction with glue
Can be useful to reinforce thin skin when suturing
Wound care
Keep dry and covered for 24 hrs Dirty wounds need recheck in 48 hrs No submersion for several more days Elevate (if applicable) Clean 2-3x daily with soap and water Watch for signs of infection APAP and NSAIDs for pain
High-risk wounds
Wounds >12 hrs old at presentation Tooth-related wounds Crush wounds Heavily contaminated wounds Wounds of relatively avascular areas Wounds involving joint spaces, tendons, or bones Severe paronychia and felons Wounds in pts with hx of valvular heart dz Wounds in immunocompromised pts
Tetanus prophylaxis in wound care
A non-tetanus prone wound in a pt who has not had a Td in the past 10 yrs
A tetanus prone wound in a pt who has not had a Td in the past 5 yrs
Any wound in an adult pt who has not had adequate immunization
Tetanus prone wounds
> 6 hrs old > 1 cm deep Stellate or avulsion configuration Associated with devitalized tissue Contaminated with soil, feces, or saliva From a missile From a puncture or crush Associated with burn or frostbite
Suture removal intervals
Scalp: 6-8 days Face: 3-5 days Ear: 4-5 days Chest/abdomen: 8-10 days Back: 12-14 days Extremity: 8-10 days Hand: 8-10 days Finger: 10-12 days Foot: 12-14 days
When to add 2-3 days for suture removal times
Extensor surfaces Age > 65 Diabetics Chronic steroid use Smokers
Informed consent for procedure/refusal
If competent can refuse
Written consent is needed before procedures
-Signature of pt by itself does not meet legal requirements
-Must give significant info to base decision on
Exceptions for informed consent rule
Age
Intoxication
Acute mental status change
Underlying medical conditions
What must you do screening exams and treat for in minors regardless of a consenting adult?
STI Pregnancy Drug, alcohol, dependency Rape Mental illness
AMA
Discover why pt wants to leave
Discuss tx option and potential for worsening sx or even death
Ask pt to sign AMA form with witness/family
Always document pt’s mental capacity and your discussion with pt
Eloping
Pt leaves without you knowing
If mental status or medical emergency can call for search and rescue
DNR
If not available, should resume care
Does not mean “no care”
Advanced Directive and Power of Attorney
Do criminals retain the right to refuse tx?
Yes, unless AMS
For crimes, what must clinicians do?
Report domestic violence
Comply with subpoena
Must avoid destroying evidence
Must provide MSE
How does EMTALA define an emergency?
A condition manifesting itself by acute sx of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health or the health of an unborn child in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.
What are the three main obligations under EMTALA?
- Any individual who comes and requests must receives a medical screening examination to determine whether an emergency medical condition exists
Examination and tx cannot be delayed to inquire about methods of payment - If an emergency medical condition exists, tx must be provided until the emergency medical condition is resolved or stabilized. If the hospital does not have the capability to treat the emergency medical condition, an “appropriate” transfer of the pt to another hospital must be done in accordance with the EMTALA provisions
- Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions.
When should one be given PRBCs?
Hgb 8-10 if symptomatic
-Pt is known to be bleeding without known source
<8 with CV dz, ACS definitely needs to be transfused
<7: just about everyone needs to be diffused
When does one need platelets and/or FFP in a transfusion?
With 5-7 units of a transfusion
What lab results can dictate the need for FFP in a transfusion?
PT 30-40
RF for aortic dissection
HTN Pregnancy Bicuspid aortic valve Coarctation of the aorta Males >55 yo Smoking
What can be found on a CXR for aortic dissection?
Widened mediastinum
S/sx of aortic dissection
Severe, persistent CP of sudden onset
Pain may radiate down the back, chest, and neck
HTN on exam
Syncope
Hemiplegia
Intestinal ischemia
Valvular regurgitation
Peripheral pulses may be diminished or unequal
Diastolic murmur may be heard (aortic regurg)
Difference of SBP by 20 on the right and left
Workup for aortic dissection
CBC CMP UA Lipid panel Troponin Remember D-dimer CXR ECG- look for LVH and inferior wall (II/III?AVF) abnormalities CT- imaging of choice MRI TEE
What are the two types of aortic dissections?
Type A- involves the arch proximal to the left subclavian artery, treat with surgery
Type B- Occurs in the proximal descending thoracic aorta typically just beyond the left subclavian artery, treat the HTN (nitroprusside, esmolol, labetalol)
Potential causes of syncope
Pulmonary embolism Anaphylaxis Severe aortic stenosis MVP Pulmonary HTN Sudden cardiac arrest HCM Cor pulmonale Orthostatic hypotension Hypoglycemia
When to do a CTA for chest?
PE
CAD
Trauma
Aneurysm
PE findings of lactic acidosis
Severe hypotension Alteration in sensorium Peripheral vasoconstriction Oliguria or anuria Deteriorating mental status Tachypnea is always present when the cause of lactic acidosis is tissue hypoxia
Fungal meningitis findings
Protein: 500-2000 mg/dL
WBCs: 50-1000
Glucose: nl to slightly low
Bacterial meningitis findings
Protein: 50-1000 mg/dL
WBCs: 1000-5000
Glucose: low (slightly to very low)
Viral meningitis findings
Protein: nl to increased
WBCs: 10-1000
Viral: nl to slightly low
Virchow’s triad
Triad of what causes vascular injury
Hypercoagulability: Changes in blood coagulation pathway, shifting balance toward coagulation
Stasis: The slowing or stopping of blood flow
Endothelial damage: Nl endothelium is antithrombotic
Etiology of hemochromatosis
Excess iron deposition in cells of heart, liver, pancreas, and endocrine organs d/t increased intestinal iron absorption, which then leads to iron deposition on organs such as liver, heart, pancreas, adrenal glands, testes, kidneys, etc
-Leads to organ dysfunction
-Some genetic causes also decrease levels of hepcidin, which inhibits iron absorption
MC autosomal recessive genetic d/o
MC cause of severe iron overload
Primary is more common than secondary
Presentation of hemochromatosis
Liver dysfunction Heart failure Hypogonadism Pancreatic insufficiency Hyperpigmentation Hair loss
Lab studies of hemochromatosis
Genetic testing: examination of HFE mutations is pivotal for dx
Transferring saturation levels
Serum ferritin
Hepatic iron concentration
Tx of hemochromatosis
Therapeutic phlebotomy (decreases total body iron) Iron chelation therapy Dietary changes
Lab findings of lactic acidosis
Anion gap- elevated anion gap or clinically significant hyperlactatemia may occur in the absence of an increased anion gap Lactate assay Serum lactate level ABG- metabolic acidosis Strong ion gap
Nl CSF findings
Appearance- clear Pressure: 50-175 mm H2O Spec gravity: 1.006-1.009 Normally neg: -Gram stain -Culture -Serology Glucose: 40-80 mg/dL Total protein: 15-50 mg/dL RBC: none (unless traumatic tap) WBC: 0-5/microL Diff: 60-80% lymph, 10-30% mono
Findings on CXR, CTA , and EKG in pt with PE
CTA- tells you where the clots are
CXR- sometimes there will be findings on this (but usually not)
-Westermark’s sign: prominent central pulmonary artery with local oliguria
-Hampton’s hump: increased opacity from intraparenchymal hemorrhage
EKG- S1Q3T3
-Very deep S in lead I
-Deep Q in lead III
-Inverted T in lead III
Stable angina vs unstable angina
Stable
-Presents as substernal CP that is nonpleuritic and exertional
-CP relieved with rest or nitrates
-Sx: dyspnea, nausea, diaphoresis, epigastric pain, shoulder pain
-EKG: ST depression
Unstable:
-CP at rest
-Sx: retrosternal CP not relieved with rest or nitro, anxiety, tachycardia, N/V, dizziness
-EKG: ST depression and/or T-wave inversions
-Neg cardiac enzymes
Indications and contraindications for treatments in STEMI and NSTEMI
STEMI: MONA-B, except nitro in right-sided STEMI or PDE-5 inhibitor use in last 24 hrs
PCI is first choice, but can do thrombolytic therapy
Antiplatelet therapy, statins
NSTEMI: MONA-B, no nitro in PDE-5 inhibitor use in last 24 hrs, NO thrombolytic therapy, statins, antiplatelet therapy, PCI or CABG
Overall, do not give O2 >94%
What are the main classifications of shock?
Distributive
Cardiogenic
Hypovolemic
Obstructive
Definition of shock
Inadequate organ perfusion and tissue oxygenation
Clinical manifestations of shock
Hypotension Tachycardia Oliguria AMS Tachypnea Cool, clammy, cyanotic skin Metabolic acidosis Hyperlactatemia
Distributive shock
Types include sepsis, neurogenic shock, anaphylaxis
Characterized by severe peripheral vasodilation
Cardiogenic shock
MI, cardiac dysrhythmias
Due to intracardiac causes of cardiac pump failure that result in reduced CO
Hypovolemic shock
Typically from hemorrhage
Due to reduced intravascular volume
MCC is blood loss
Obstructive shock
Includes:
Massive PE
Tension pneumo
Cardiac tamponade
General shock treatment
Oxygen
IV access
Draw blood
IV fluids
Total volume maximums for the different types of shock?
Obstructive shock or cardiogenic shock: 500-1000 mL
RV infarction or sepsis: 2-5 L
Hemorrhagic shock: >3-5 L
What is the first cardiac marker that will be elevated when someone’s having an MI?
Myoglobins
Order of blockade of anesthesia
Pain Cold Warmth Touch Deep pressure Motor
Max dosage of lidocaine
4.5 mg/kg without epi
7 mg/kg with epi
Max dosage of bupivacaine
2.5 mg/kg with epi
Initial sx of anesthesia toxicity
Perioral tingling/numbness Metallic taste Lightheaded/dizzy Visual/auditory hallucinations -Tinnitus, difficulty focusing Disorientation/drowsiness
Components of lidocaine
Rapid onset (1-2 mins to peak) Relatively short duration of action (~1 hr) Acidic, so burns briefly on injection -Can buffer 10:1 lido: sodium bicarb
When should epi not be included with anesthesia?
Ears Nose Fingers Toes Penis
What dosages of lidocaine are available?
1% -MC used 2% -Allows you to use less medicine (small spaces) -Sometimes used for nerve blocks
Dosages of bupivacaine
- 25%
0. 5%
Components of bupivacaine
Slower onset (5-10 mins to peak)
Longer acting (~4 hrs and up)
Commonly used for nerve blocks
Sometimes mixed with lidocaine to provide rapid onset with longer duration
Has been shown to reduce residual pain, even after it has worn off
Allergies to anesthesia
Lidocaine and Novocaine are in different classes of anesthetics, so an allergy to novocaine usually does not indicate an allergy to lidocaine
Many lidocaine allergies are actually rxns to the preservative in multi-dose vials
Non-traditional anesthesia
-Ice or injection with Benadryl or even saline will all provide some degree of anesthesia
Causes of first degree heart block
Meds
Ischemia
Lyme disease
Causes of Mobitz type I
Meds
Post MI
What to not use in abx for diabetics
FQs
Reversible causes of cardiac arrest
Thromboembolism Tension pneumo Tamponade Toxicity (TCAs, BBs, CCBs, digoxin) Hypoxia Hypovolemia Hypo/hyperkalemia Hydrogen ions
