Minor Surgery Flashcards
_______ fluids of ALL patients should be considered infectious.
blood and bodily
_______ is the most frequently occurring work-related infectious disease.
Hepatitis B
Anesthetics are dividided into 2 groups:
esters and amides
2% Glutaraldehyde has a (low/high) tissue toxicity.
Low
Name 2 required universal precautions (OSHA):
Use barriers (gloves, ppe) Sharps management
Use sterilization for _____, disinfecting for ______.
S - tools
D - living tissue
2% Glutaraldehyde takes how long to work?
10 mins to disinfect
10 hours to sterilize
Boiling can effectively sterilize at:
> 30 mins
Dry heat can effectively sterilize at:
160C / 320F x1 hour
Autoclave rules:
15 psi at 121c for 15 mins
Intact skin can be disinfected with:
10% betadine x3
0.4% chlorhexidine gluconate
Why do we irrigate with normal saline instead of H2O2 or other antiseptics?
ineffective at disinfecting
slows wound healing
promotes tissue necrosis
If skin is punctured, and large items are still in the skin, you should:
Secure and refer
Let puncture wounds heal by ___ intention.
second or third - in case something is still inside
Dont suture wounds older than:
8-12 hours, up to 24 if very clean
24 hours on the face/neck (good blood supply)
If you can’t rule out these kinds of damage, you should always refer:
nerve
tendon
vasculature
bone
Normal scar healing is called ______, while extending beyond the original area is called ________.
hypertrophic
keloid
Healing stages:
1 - hemostasis/coagulation
2 - inflammation
3 - proliferation (granulation)
4 - remodeling
Healing stages - Hemostasis is also called _______, and is characterized by _____ and formation of a _______.
coagulation
platelet aggregation
fibrin clot
Healing stages - Inflammation occurs on days ______. Cytokines are secreted by ________, complement cascade is triggered, and _______ arrive in 5-6 hours, staying 3-4 days to destroy bacteria.
1-4 (immediately)
platelets
neutrophils
Healing stages - Inflammation:
__________ remove dead neutrophils, necrotic tissue, and microbial pathogens on days _______.
macrophages
1-4
Healing stages - Inflammation:
re-epithelialization
fibroblasts and epithelial cells bridge across the wound, finished bridging by days 3-4
New keratinocytes proliferate ____ days after injury.
1-2
Neovascularization is:
And occurs during what healing phase?
angiogenesis, brings oxygen and nutrients
proliferative
Remodeling strength at 3-4 weeks:
30-40%
Remodeling strength at 1 year:
80%
Bromelain can help increase _______ formation.
collagen
Healing intention - primary:
suture a clean wound
bandage and let heal
Healing intention - secondary: full thickness, into subQ
left open, healed by granulation
used with significant tissue loss or contamination
Healing intention - tertiary:
without significant tissue loss -> clean, pack, cover, leave open 3-5 days, then suture if non-infected
* dog bite
* puncture with contaminated tool
> you may want to reopen if the skin starts healing over too soon
3 important stitches to be comfortable with if you want to do minor surgery:
Simple interrupted
Vertical mattress
SubQ
Simple interrupted stitching may cause _______ scarring
railroad
Vertical mattress is (easy/hard) to evert under tension.
easy
better for cosmesis
Horizontal mattress is good for (high/low) tension wounds and (fragile/dense) tissue
high
fragile (thin skin)
Deep or buried stitches - use ______ suture.
absorbable (vicryl or dexon)
for large or deep wounds
What are some indications for using subcuticular/intradermal running stitches:
dermal layer
not visible
eliminates tracts
linear wounds with little tension
Running stitches are:
less secure
high risk of infection
quick to put in
not cosmetic
3-point, half-buried stitches are good for:
triangular flaps without strangulation
Two main classes of suture materials:
absorbable (natural, synthetic)
non-absorbable
Natural absorbable sutures are digested by:
Examples?
body enzymes
Catgut, chromic catgut
Are natural or synthetic absorbable sutures less reactive?
Synthetic (vicryl, dexon)
_______ sutures are hydrolyzed and easy to tie.
synthetic
Characteristics of silk sutures:
high tissue reactivity
easy to tie
Characteristics of stainless steel:
minimal tissue reactivity
permanent
Characteristics of polyester/polybutester:
high tissue reactivity
Characteristics of nylon/ethilon:
low tissue reactivity, low risk of infx
slips easily
monofilament
Staples:
minimal tissue reactivity, low risk of infx
fast
uncomfortable
Use ____ knots per gauge:
one knot over gauge (5 knots for a 4-0)
Suturing face/neck - gauge, remove:
5-0, 6-0
3-5 days
Suturing arm/hand - gauge, remove:
4-0, 5-0
7-10 days
Suturing trunk/leg/foot/scalp - gauge, remove:
3-0, 4-0
7-14 days
Reverse cutting is (most/least) common
most common for procedures
Dress wounds for:
absorption of drainage
support
moisture for epithelialization
limits movement
Post-op, keep wounds + dressing dry for _____ hours.
24-48
Infections occur ____ days post-procedure, and the most common pathogen is ___________
4-10 days (normal inflammation occurs before day 4)
staph aureus
Blood collection following surgery is called ______, happens _____ hours after surgery, and may lead to infection or ______.
hematoma
24-72 hours
dehiscence
Wound rupture along the incision after suture is closed is called ______. You can re-suture within ____. After that window, you want to:
dehiscence
48-72 hours
let it heal by secondary intention
Local antisthetics block ___ reuptake, to prevent:
sodium
depolarization and propagation of pain stimuli
10cc of 1% lidocaine = __ mg
100mg lidocaine
IM injection angle:
90 degrees
SubQ injection angle:
30-45 degrees
Intradermal injection angle:
5-10 degrees
Amides are metabolized in the _____, and true allergies are (common/rare).
liver
rare
Lidocaine/xylocaine has a ___ min onset, ___ min duration.
1-10 mins to onset
30-60 min duration
Max dose of lidocaine in a child:
3.3-4.5 mg/kg, not to exceed 75-110mg
Max dose of lidocaine in an adult:
4.5 mg/kg, not to exceed 300mg (30cc of 1%)
Bupivacaine/marcaine has a ___ min onset, ___ hour duration. Indicated for:
8-12 min onset
3-4 hour duration
digital block
Max dose of bupivacaine/marcaine:
4 mg/kg of 0.25%, not to exceed 200mg
Esters are metabolized in ________ by pseudocholinesterase
peripheral plasma
more reactions
3 ingredients in TAC:
Tetracaine (ester)
Epinephrine
Cocaine
3 ingredients in TAC:
Tetracaine (ester)
Epinephrine
Cocaine
We pull back on the plunger before injecting to avoid what adverse reaction?
Inadvertant intravascular injection
excessive dose
Too much anesthetic, give:
oxygen
CNS depressant may cause hypotension, then bradycardia or arrest
Treat mild allergic reactions with _____.
Treat severe allergic reactions with ______.
diphenhydramine (15 mins)
epinephrine and oxygen
Allergy is mc with what type of anesthetic?
esters
In true anaphylaxis reaction, how do pulse and BP change?
HR up / BP down
[vs. autonomic response - both go up]
Uses of epinephrine: (vasoconstriction)
- decrease oozing
- prolong duration by limiting absorption into tissues
- decreasing risk of toxic reactions by reducing circulating anesthetic
Side effects of epinephrine:
anxiety restlessness tremor palpitations tachycardia
Epinephrine dose for anesthetic use:
1:200,000
< 0.2 mg
Epinephrine dose for anaphylaxis:
1:1000
Contraindications of epinephrine use:
End-arteries (fingers, nose, toes, penis, clitoris, ears)
MAOIs, TCAs, thyrotoxicosis, severe CAD
caution with PVD, HTN
3 parts of the sterile field:
- physician - gloves, washing, mask
- patient - sterile drape, incision area
- tray - tools, materials
Contraindications to ND PCP doing minor surgery
- location - lesion on nose, eye, axilla, groin, post neck
- large size / blood supply
- depth - lipomas can be intertwined in mm/bone
- young children
- pt on anti-coags / with bleeding disorder
- pt on a corticosteroid
- pulsating lesion
- keloid forming pt
- systemic illness with depleted immune system
Tissue destruction methods:
Never use if:
cryotherapy
electrosurgery
** if you want to biopsy! **
Cryotherapy - freezing with _______, which leads to anoxia and death.
“cryogen”
- HistoFreeze - aerosol
- Dry ice
- Nitrous oxide
- liquid nitrogen - MC
If you are going to freeze warts, start by:
using #10 scalpel blade to shave it down to black dots or pin-prick bleeding, THEN cryo
Cryotherapy is indicated for:
- warts
- skin tags (acrochordon)
- seb keratosis
- actinic keratosis
Dry ice isn’t used much anymore, because:
it’s simple, cheap, but not very effective
Transport liquid nitrogen in a:
Never use straight from bottle, risk of:
Dewar bottle
HPV transmission
Liquid nitrogen - freeze, thaw, refreeze, with ___mm zone around lesion.
May cause __________
2-3 mm
depigmentation
Types of electrosurgery:
- Electrocautery - indirect, precise
* Hyfrecation - direct
Describe proper excisional biopsy technique:
3:1 elliptical excision with 30 deg corners
#15 scalpel
parallel to Langer’s Lines
Punch biopsy technique:
traction perpendicular to Langer’s Lines
1-2mm beyond edge of lesion
full thickness of dermis
When do you use #10, 11, and 15 scalpels?
11 - puncture abscess, incision, stabbing
15 - blunt dissection, excision, trimming
10 - like 15, thick skin
When do you use non/toothed forceps?
Toothed adson - does not crush skin
Toothless - crushes skin, foreign body removal
When do you use iris vs metzenbaum scissors?
Iris - fine dissection, not for sutures
Metzenbaum - blunt dissection
Healing stages - Proliferation occurs on days _____. ______ deposit ______, in order to strengthen the wound.
5-20
Fibroblasts
Type III collagen
Healing stages - Wound Remodeling occurs from day ______ onwards. ______ formed during proliferation is broken down.
21
Type III collagen
Healing stages - Wound Remodeling
Type III collagen is replaced by _______, and collagen fibers are ______.
Type I collagen
Cross-linked
Healing stages - Proliferation
Fibroblasts differentiate into _______, and cause contracture.
Myofibroblasts
Which injectable anesthetics are amides?
Lidocaine
Mepivacaine
Bupivacaine
Which anesthetics are esters?
Procaine
Tetracaine
Benzocaine
Indications for electrocautery:
− Obtaining hemostasis
− Removing acrochordons
− Draining subungual hematomas
− Removing actinic + seborrheic keratosis
− Removing other benign lesions often combined with curettage
Esters metabolize into ______, which is associated with true allergic reactions.
PABA
If a patient is allergic to PABA, they may also be allergic to _______, which is included in amide anesthetics (unless single use).
Methylparaben
Use a preservative-free amide for pts allergic to esters/PABA
1cc of of 1% lidocaine solution = __ mg
10mg
Empirical antibiotic tx of an infected wound?
Cephalexin 500mg tid-qid
-or-
Clindamycin 300mg tid if pt is allergic to penicillin or if they have a known hx of MRSA
3 reaction types to local anesthetics:
Toxic
Allergic or hypersensitive
Autonomic
Signs of toxic rxn to local anesthetics?
Tx?
CNS: tinnitus, numbness of the lips, light-headedness, N/V
Cardio: hypotension, bradycardia
Tx: oxygen
Signs of allergy rxn to local anesthetics?
Tx?
Rash, erythema, urticaria, angioedema
Hypotension, bronchospasm
Tx: diphenhydramine, if severe epinephrine and oxygen
Signs of autonomic rxn to local anesthetics?
Tx?
Tachycardia, sweating, dizziness, faintness, syncope
Tx: pt should lie down
