minor surgery Flashcards
what bodily fluids are potentially infectious
blood, semen, vaginal secretions, CSF, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva, unfixed tissue or organs,
potential forms of transmission of blood born pathogens
contaminated bodily fluid that contacts eyes, mouth, nose, broken skin, or stick with a needle
what does universal precautions mean?
blood and bodily fluids from all patients should be considered potentially infectious
what is the most frequently occuring work related disease BBP
HBV
accidental needle sticks are most likely to transmit what infection
HIV
only safe ways to recap needles
one handed or hemostat change
when should sharps be placed in a sharps container
asap
Needle holder types, and purpose
blunt nosed, ratcheted
hold needle and suture- toothed better grip more damage to needle
Scissor types and uses
iris scissors: TISSUE ONLY
Suture scissors- suture cutting
Forceps types and uses
adsons with teeth- for tissue holding- cause less trauma to samples
Adsons without teeth- hold suture, foreign bodies, pick up from sterile field - NOT TISSUE THEY CRUSH IT
splinter forceps- removal of foreign body
Hemostats other names and use
other names: clamps, forceps, kelly’s , mosquitoes
remove scalpel blades, hold tourniquets, clamp vessels, hold skin tags/tissue that is to be removed
scalpel blade #11 use
stabbing, incising skin such as I/D
scalpel #15 use
standard blade for excision, trimming, dissecting tissue
scalpel #10 use
for tough skin, back and scalp- work hoarse
how to clean medical instruments
clean with plastic brush under cool water after use
dry
lubricate with instrument milk
sterilize instrument
definition of sterilization
destruction of all living organisms including spores
definition of disinfecting
reduction of microorganism population without achieving sterility - spores end up left on surface
Definition of a disinfectant
germicidal substance used on inanimate objects to kill pathogenic microorganisms but not all
definition of antiseptic
chemical agent applied to BODY to kill or stop growth of pathogenic microorganisms
methods for sterilization of instruments
Chemical , boiling, hot air oven, auto clave, gas, radiation , disposable instruments
how to sterilize with chemicals
Alcohol 70% and chlorhexidine 5% - emergency use only- 2 minutes- DOES NOT STERILIZE
2% GLUTARALDEHYDE soak for 10minutes to disinfect, 10hrs to sterilize
Boiling to sterilize
100 degrees C or 212 F for 5min disinfects
Boil 30minutes at sea level to sterilize
Hot air oven to sterilize
160 degrees C , 320 F for 1 hr
Autoclave
sterilize wrapped instrument packs- uses steam under pressure for 15minutes
More zeros on a suture label mean what
finer thread and better cosmetic results
Where should finer sutures be used
face , beck , back of hands , where concern for scaring
Where is larger suture used
scalp, back, trunk, palms, soles , areas of greater tension
monofilament versus multifilament
Monofilament- single strand, less resistance with use, less likely to harbor microbes. Tie easily, knots tend to slip and break
Multifilament - several strands braided together, stronger and pliable, slip less easily. Tend to harbor microbes,
Absorbable suture versus non absorbable
Absorbable- for locations where it will not be removed such as deep wounds to close sub q space
non absorbable - dont break down and must be removed or used for permanent grafts
categories of absorbable sutures
Natural and synthetic
Natural - made from mammalian collagen and body enzymes break them down
Synthetic- polymers which are hydrolyzed over time to break down - less reaction from the body
Name the natural absorbable sutures
plain cat gut- breaks down over 7-10 days , may have tissue reaction
chromic cat gut- delayed break down over 2-3 weeks less reaction in tissue
Name synthetic absorbable sutures
polyglactic or vicryl - both braided and not. smooth, easy to tie, holds for 4-7 weeks good for SUBQ
Polyglycolic or dexon - monofilament, no reaction, several weeks - SUBQ
polydioxanone PDS - monofilament- 6 weeks
Name synthetic absorbable sutures
polyglactic or vicryl - both braided and not. smooth, easy to tie, holds for 4-7 weeks good for SUBQ
Polyglycolic or dexon - monofilament, no reaction, several weeks - SUBQ
polydioxanone PDS - monofilament- 6 weeks
name non absorbable sutures
silk- braided, easy to tie, increased infection risk, 1 year- vessel ligation
nylon - monofilament, low reactivity, high tensile strength, need extra knots tied- good for skin and SubQ
Polypropolyene- flexible, strong, slick. more expensive
stainless steel- permanent- abdoment, sternal wound, tendon repair
polyester
when can you use a steri strip
for superficial lacerations, wound is clean, little tension
locations that should never have a steri strip used
knees, elbows, hands, feet, inside mouth, groin
never wrap around digits= torniquet
Dermabond use
apply 3 thin layers, set for 3 minutes, as strong as sutures, slough off as wound heals usually 10 days
types of needles
reverse cutting needle- most common and for suturing
types of ties and uses
two handed- most secure
one handed- fast, good for deep space
instrument- conserving sutures- most common type
to what length should ends be cut
1/8th in
where should knots be positioned at the end of the procedure
all to the superior or medial side to prevent being absorbed into skin
at what angle should the needle enter and leave skin
90 degrees / right angles
what should your stich due to skin edges for best healing
evert them
what are 3 ways to lesson tension on a wound when suturing
use deep buried sutures
undermine the wound borders
use more sutures
what is the rule of halves
first stich in middle of wound, each following stich halves the remaining space
what stitch causes railroad tracking scars, is time consuming, is the most common stich
simple interrupted
what stitch is used for eliminating dead space in deep wounds and connects the sub q space
deep buried
what type of suture should be used for deep buried
vicryl or dexon absorbable
what stitch is good for high tension wounds like palms or soles, and can also close dead space. but may also result in railroad track scars
vertical mattress
what is the technique for a vertical mattress stich
far, far, near , near OR far, near, near , far
stich that is made up of 2 interconnected simple interrupted stitches, forms square
horizontal matress
stitch with best cosmetic outcome but least strength
running stitch- subq or intradermal
what type of wounds can safely be closed with a running stitch
clean, linear, with little tension
what is the fastest stitch but least cosmetically supportive
continuous running
what stitch is used for triangular wounds
three point or half burried
how to do a three point stich
secure point with single subcutaneous stitch then secure sides with simple interupted stitches
what does epinephrine help with
decreases bleeding, prolongs duration of anesthetic, decrease risk of toxic reaction to LA
what to local anasthetics due to stop pain signals
block sodium uptake into cell in nerves impacting pain nerves first because they are the smallest
what are the three types of adverse reactions to local anesthetics
toxic- overdose due to injecting into a vessel- avoid this by pulling back before injecting
autonomic - vasovagal
allergic
signs of local anesthetic toxicity
tinnitus, numbness of lips, lighheadedness, N/V, shivering, tremors, seizure, CNS depression, low blood pressures.
how to treat toxicity
oxygen
Lidocaine
amide local anesthetic
rapid onset in 10min
last up to 1hr
common dosing: 2-6cc of 1% solution for minor office procedures
MAX dose300mg or 30cc should still be less than 4.5mg/kg
bupivacaine
amide local anesthetic
slower onset 12min
longer duration at 3-4hrs
Max dose 4mg/kg of .25% solution
procaine
ester anesthetic
alternative to lidocaine
slower onset , lasts about 1 hour
allergic reactions are more common
max dose for epinephrine when mixing it with your anesthetic
less than 0.2mg
areas in which epinephrine is contraindicated
ears, nose, toes, fingers, genitals,
what size needle should you use for injecting anesthetic
smallest possible
what are the 3 rules of giving anesthetic
use smallest amount while still being effective
never exceed max dose
ensure it has taken effect before starting the procedure - poke or pressure test
can you do a minor office procedure on a lesion know or suspected to be malignant
NO - refer to derm
potentially cancerous lesions described as what
assymetric
irregular borders
variable color especially 3+
larger than 6mm in diameter
change in appearance over time
bleed or itch
areas not allowed to have minor surgery done by us
eyes, nose, axilla, groin , posterior triangle of neck
reasons to refer out
cancer or suspect cancer
off limits area
pt has coagulation disorder
know keloid former
serious systemic illness
How to remove nevi
eliptical excision, shave biopsy, punch biopsy, hyfrectation.
suspicious at all= punch or elliptical with biopsy
sun exposed are, slow growing, papule, becomes ulcerated with rolled edges . May be pearly with fine telangiectasias
basal cell carcinoma
most deadly skin lesion
melanoma
sun exposed area, firm and irregular with scaly , keratotic, bleeding and friable surface
squamous cell carcinoma
what is the precursor for squamous cell carcinoma
actinic keratosis
red scaly, sandpaper patches on light exposed area
tx with cryo, flourouracil cream, hyfrectation, shave excision
actinic keratosis
common on head, neck , dorsum of hands, foreams, and trunk in elderly.
flat topped with stuck on appearance, deeply pigmented with granular surface
tx with cryo, curettage, shave, elliptical
seborrheic keratosis
fleshy , pedunculated lesion found on neck, armpit
remove wth lift and snip then cauterize or firm pressure
papillomata
benign, inflammtory mass of blood vessels and friboblasts. Forms quickly after trauma or infection . Looks like a polyp with collar around base, bright red, bleeds easily
pyogenic granuloma
due cryo, cureette, excision
how to ID a spider vein
disappears with pressure
benign dermal lump, usually on legs, feel like lentils in skin and are mobile
dermatofibroma
elliptical excision
on light exposed skin, grows fast, round with rolled edges and central keratin plug, often inflamed
keratocanthoma
usually spontaneously resolve in 6 months, curette, or excision with biopsy
small, pearly, hard papules with umbilicated center
molluscum contagious
usually self resolve
consider homeopathics or topical melissa or glycyrrhiza
caused by HPV, usually on plantar surface of feet or hands, or genitals
verrucae or warts
start with topical treatments- duct tape, salicyclic acid, podophyllin, thuja, tea tree oil
cryotherpay - shave down wart with #10 blade, until it bleeds or pt feels discomfort , apply liquid nitrogen with cotton tipped applicator until zone 2-3mm beyond wart border. let thaw and repeat twice more
conditions that can be treated with elliptical excision
benign nevi, dermatofibroma, warts, seborrheic keratosis
how to do elliptical excision
Measure length: width ratio of 3:1, with 30degree angles , include 2 mm health tissue border in measurements
orient the excision parallel to skin tension lines , draw it
field block
prep with betadine x3
set up sterile field
make first cut with 15 blade through the skin and subq
cut perpendicular to skin while applying tension
undermine with iris scissors
mark one edge of specimen - place in 10% formalin
control bleeding with gauze , pressure, electrocautery
undermine lateral edges
close deadspace if needed with deep b
place sterile dressing
how to do shave biopsy
raise lesion with intradermal anesthetic at its base
stabilize and stretch skin on either side
use 15 blade or razor blade
slice through a very thin portion of skin using one directional strokes, keeping blade parallel until fully removed.
how to perform punch biopsy
small obviously benign lesion
stretch skin perpendicular to skin tension lines at time of punch to form oval
twist trephine down through dermis
lift specimen with toothed forceps, cut base with iris scissors
cautery or pressure as needed to hemostasis
place suture if needed apply small dry dressing
how to help an abscess become fluctuant
warm compressions, poultices, homepathic hepar sulph, antibiotics
how to do I/D procedure
obtain informed consent
follow sterile technique, is not a sterile procedure
anesthesia- ensure its adequate
cut parallel to resting skin tension lines
cut with 11 blade across full incision site
culture drainage
used gloved finger to break up adhesions and loculations
irrigate well with normal saline
loosely pack with 1/4-1/2 in lodoform or gauze, leave a tail out to wick
apply thick clean dry dressing
post I/D care
24hr after procedure start warm soaks leaving packing in do this 3-4 times daily
redress with clean dry dressing
follow up within 2 days
after reassessment continues soaks for 7 days or until healed
how to treat cysts
same as abcess but do not rupture capsule as the whole thing needs to be removed to prevent recurrence
close with deep sutures
send specimen to pathology
how to treat lipoma
prep with sterile field
linear incision over lipoma follow skin tensionlines
blunt dissection to remove lipoma
ligate tethering vessels with absorbable suture
probe to ensure no lobes left
close dead space , remove extra skin if needed to approximate
when to refer a laceration
cut tendon, cut nerve, on face, foreign body deeper than fascia or near critical structure , very large with significant bleeding
how to treat puncture
flush with NS in 30cc syringe and blunt 18g needle , debride if needed. leave open and dress with sterile dressing
types of wound closure
primary , delayed, open or 1 degree, 3rd degree, 2ndary
immediate suturing of wound, it is less than 12 hours old, very clean
primary closure
visibly contaminated wounds, or seen after 12hrs. must be cleaned well, packed with moist dressing and monitored for 4 days. closed if no signs of infection.
delayed or 3 degree
very contaminated or already infected wounds, and will cause more scarring as a result. wound left open to heal
second degree or open treatment
four phases of wound healing
hemostasis, inflammation, granulation, remodeling
when does granulation begin and how long does it last
days 3-4 after injury and lasts for 3 weeks
when does remodeling occur
after 3 weeks from injury over the next year
contraction versus contracture
contraction is good- normal process
contracture- too tight of skin causes scaring limiting motion
nutrients to promote wound healing
vitamin C, zinc, copper, vitamin E, flavonoids
what does vitamin C help with
collagen formation and reducing inflammation
1000mg multiple times per day
what does zinc help with
supports DNA, RNA, and collagen formation and promotes cell growth
30mg picolinate per day
what does vitamin A help with
regeneration of epithelial cells and recovery from burns
25,000 IU daily
what do B vitamin do
help with collagen cross linking
what does copper do
supports collagen cross linking at 2mg per day
what does vitamin E do
reduces scar formation and adhesions topically
reduce scarring at 400IU internal daily
flavonoids
reduce scars 1:2 ratio with vitamin C
bromelain
reduces inflammation, minimizes scarring
when to remove face and neck stitches
6 days or less
when to remove stitches in arms or hands
7-10days
when to remove stitches in trunk, legs, feet, scalp
7-14 days
size suture to use for skin on face or neck
5-6 nylon or prolene
size suture to use on skin of arms or hands
4-5 nylon or prolene
suture to use on skin of trunk, legs, feet, scalp
3-4 nylon or prolene
size of suture to use on buried stitches
3-4 vicryl or dexon
how to remove sutures
grasp suture ends with smooth forceps
pull knot and suture across axis of closed wound to prevent reopening
cut suture as close to skin as possibel with scissors
how to prevent wound infection risk
achieve hemostasis, eliminate dead space, thoroughly clean wounds, follow sterile technique
when does redness and itching become a potential sign of infection
after 4 days since the procedure
common homeopathics for wound infections
apis and ledum
swollen slowly enlarging erythematous mass along or beside the suture line that presents 24-72 hr post procedure
hematoma
if large- reopen, carterize and leave open
causes of wound reopening or dehiscence
infection, hematoma, inadequate undermining, poor suture technique, excessive activity, removing suture too soon
paronychia is what and caused by what
infection of folds around nail
caused by staph, HSV, fungus. secondary to hangnail, sliver or injury
signs of purulent tenosynovitis
slight flexion of the finger at rest
fusiform swelling of finger
pain on passive or active extension
tenderness along tendon sheath into palm
subungual hematoma
release pressure with electrocautery through the nail or hot paper clip or bore with needle tip
ganglion cyst
slow growing, usually on dorsal wrist. most resolve spontaneously.
due surgery if there is pain, limited funcion, cosmesis
distribution of ulnar nerve
pinky and ring finger dorsum and palmar
radial nerve distribution
back of thumb and base of first three digits , up dorsum of arm
median nerve distribution
thumb to lateral edge of ring finger on palmar surface and middle three fingers on dorsal surface
from how high up can sterile instruments be dropped onto a sterile field
4 inches
what to document
hx of any wound
pt age, prior tx , allergies, tetanus status, meds,
general beginning condition, vitals
describe wound- location, size, length, superficial or deep, clean or contaminated, and type
function of nerves and tendons
that informed consent was attained written and oral
wound pep, anesthesia, suture material and size, type and number of stitches, dressings, post op instructions provided, follow up care provided
