Minor Surgery Flashcards
What are universal precautions?
OSHA - things to keep YOU (as provider) protected
MC transmitted infx
Hep B
2% Glutaraldehyde: _____ to disinfect, _____ to sterilize
10 min to disinfect
10 hr to sterilize
How long do you need to boil to sterilize?
> 30 min
Dry heat sterilization
160’C/320’F for 1 hr
Autoclave sterilization
15 PSI at 121’C for 15 min
*most efficient and reliable form of sterilization
You ______ tools, you ______ people
Sterilize tools
Disinfect people
How do you disinfect intact skin?
10% betadine X3
0.4% chlorhexidine gluconate
How do you disinfect an open wound?
irrigate with normal (0.9%) saline
*do NOT use H2O2
Puncture with nerve, tendon, joint involvement or in chest/abdomen
Stabilize (secure large objects) and refer
Something to consider with puncture wounds
Pt last tetanus shot
Do not suture wounds older than
8-12 hr on body or 24 hr on face
Hypertrophic vs. keloid scar
hypertrophic is normal healing
keloid extends beyond the original area of wound
Healing stages
1) Hemostasis (coagulation): fibrin clot
2) Inflammation: immediately (days 1-4), cytokines and complement
3) Proliferation (granulation): 3-21 days, angiogenesis
4) Remodeling: 3wk to 6-18 mp. Contraction (normal) and contracture (abnl)
During inflammation stage of healing: _________ in 5-6 hrs, last 3-4 days to destroy bacterial
Neutrophils
During inflammation stage of healing: _________ transition from inflammation to repair and phagocytize
Macrophages
During inflammation stage of healing: __________ migrate w/in 24-48 hr to repair wound (re-epithelialization)
Basal cells
During inflammation stage of healing: _________ proliferate 1-2 days after injury
New keratinocytes
During remodeling: ____% strength by 3-4 wks, ____% at 1 year
30-40% at 3-4 wk
80-90% at 1 hr
__________ is normal due to myofibroblasts and orientation of collagen
Contraction
________ is abnormal formation of tight scar due to excessive contraction
contracture
Name this healing intention:
cut with kitchen knife - clean, fresh; we can clean and close it up; 8-12 hr
Primary intention
Name this healing intention:
Full thickness (into SubQ), older, leave open and allow to heal by granulation; usu. w/ significant tissue lost or contamination/infection; < 12 hr
Secondary intention
Name this healing intention:
Grossly contaminated wounds without significant tissue loss can be cleaned, packed, covered and left open for 3-5 days - can be sutured after this if not infx; e.g. dog bite
Tertiary (delayed primary) intention
may cause railroad tract scarring, eversion may be difficult
Simple interrupted
easy to evert edges under tension, better for cosmesis
Vertical mattress
suture for high tension wounds and fragile tissue; palms or soles
Horizontal mattress
larger, deeper wounds; requires _____ sutures
absorbable
Deep/buried suture
dermal layer, not visible, eliminates tracts; linear wounds with little tension; can use absorbable or non-absorbable sutures
SubQ/intradermal running
rapid, non-cosmetic, less secure; HIGH risk of infx
Continuous running
triangular flaps without strangulation
3 point/half-buried
Natural sutures are digested by
body enzymes
Plain catgut (suture)
natural, absorbable, some reactivity
T1/2 = 7-10 days
Chromic catgut (suture)
natural, absorbable, less reactivity than plain catgut
chromic salt delays absorption
T1/2 = 2-3 wk
least reactivity of sutures, hydrolyzed, easy to tie
synthetic (vicryl, dexon, PDS)
Polyglactic/vicryl (suture)
synthetic, absorbable, braided and monofilament
T1/2 = 2-3 wk
*braided = stronger BUT incr. chance of infx
Polyglycolic/Dexon (suture)
synthetic, absorbable, monofilament
T1/2 = 2-3 wk
Polydioxanone/PDS (suture)
synthetic, absorbable, monofilament
T1/2 = 4-6 wk
Silk (suture)
natural, non-absorbable, braided, easy to tie
HIGH tissue reactivity
Stainless steel (suture)
natural, non-absorbable, permanent
minimal tissue reactivity
Polyester/Polybutester (suture)
natural, non-absorbable
HIGH tissue reactivity
Nylon/ethilon (suture)
synthetic, non-absorbable, monofilament, slips easily
low tissue reactivity, low risk infx
Polypropylene/prolene (suture)
synthetic, non-absorbable, monofilament, similar to nylon
if using steri-strips, do NOT
encircle digits = tourniquet
______ helos steri-strips stick better
benzoin
wound closure that is fast, low risk of infx, uncomfortable
staples
Face/neck: suture gauge ____, remove after _____
5-0, 6-0
3-5 days
Arm/hands: suture gauge ____, remove after _____
4-0, 5-0
7-10 days
Trunk/legs/feet/scalp: suture gauge ____, remove after _____
3-0, 4-0
7-14 days
needle used for cosmetic procedures
conventional cutting
MC needle use for most minor surgery procedures
reverse cutting**
needle that pierces and spreads without cutting, used in bowel, muscle, and fascia
tapered
needle used to dissect friable tissue instead of cutting; liver, kidney, spleen, cervix
blunt
Post-op: keep wound/dressing dry for ___ hours and limit movement; redress every ___ days.
24-48 hr
2-3 days
Post op: remove sutures with _______ with knots pulled across
iris scissor or #11 scalpel
if dehiscence occurs, re-suture within
48-72 hrs
as long as it’s not infected!
local anesthetics block ____ reuptake to prevent _______ of pain stimuli
Na
depolarization
(called non-depolarization block)
10cc of 1% = ___ mg
100
just add a zero
Amides are metabolized in
liver by microsomal enzymes
True allergies are rare with amides/esters
amides
topical amides
lidocaine and EMLA cream/patch
injectable amides
lidocaine
bupivacaine
mepivacaine
Lidocaine: _____ onset and ____ duration
onset: 1-10 min
duration: 30-60 min
Bupivacaine: _____ onset and ____ duration
onset: 8-12 min
duration: 3-4 hr
Max dose of lidocaine in child
3.3-4.5 mg/kg of 1%, not to exceed 75-110 mg total
Max dose of lidocaine in adult
4.5 mg/kg of 1%, not to exceed 300 mg (30cc) total
Max dose of bupivacaine in adult
4 mg/kg of 0.25%, not to exceed 200 mg
Which anesthetic is used for digit blocks
bupivacaine
bupivacaine SE
heart block
BLOCKS - used for digit block and MAJOR SE of ht block
Mepivacaine: _____ onset and ____ duration
onset: 8-12 min
duration: 2-2.5 hr
*less drowsiness than lidocaine
Max dose of mepivacaine in adult
5 mg/kg of 1%, not to exceed 400 mg
Esters are metabolized in
peripheral plasma by pseudocholinesterase
topical esters
benzocaine
proparacaine
cocaine
TAC (tetracaine + adrenaline/Epi + cocaine)
injectable esters
procaine
topical ester that is poorly absorbed, need at least 10%
benzocaine
topical ester used in ophthalmology, < 1 min onset, 15 min duration
proparacaine
topical ester used in ENT procedures, < 1 min onset, 1 hr duration
cocaine
topical ester that is CHEAP and FAST
TAC (tetracaine + adrenaline/Epi + cocaine)
slower onset and same duration as lidocaine; allergic rxn common
Procaine (an ester)
toxic rxn to anesthetics leading to hypotension, bradycardia, cardiac arrest. tx with ____
high dose O2 (helps body metabolize anesthetic)
allergic/hypersensitivity to anesthetics; tx mild with _______ and severe with ______
mild: diphenhydramine
severe: Epi and O2; or if in wild follow Epi w/ diphenhydramine and steroids
Uses of Epi
1) decreases oozing/bleeding
2) prolongs duration/decreases absorption of anesthetic
3) decreases risk of toxic rxn (b/c decrease absorption)
injectable Epi dose for minor surgery procedures
1:200,000 with MAX of 0.2 mg
antidote to Epi toxicity/OD
administer IV push of Mg++ and B6 to increase COMT metabolism
Never use Epi in
end-arteries (fingers, toes, penis, nose, clitoris, ears)
EPI C/I
MOA-I, TCAs, Thyrotoxicosis, severe CVD
caution in pt with PVD, HTN
ND’s can perform _________, cannot _________
can: uncomplicated procedures that involve superficial structures
cannot: go into fascia or muscle
List of things ND’s canNOT do
1) eyes, nose, axilla, groin, neck
2) large size/blood supply
3) depth
4) young children
5) pt. on anti-coag or w/ bleeding d/o
6) pulsating lesion
7) keloid formers
8) immunocompromised
Never use ________ if you’re suspicious of malignancy
tissue destruction methods (cryo, electro)
Liquid nitrogen is stored in
Dewar bottle - can last weeks or months
liquid nitrogen procedure
freeze, thaw, refreeze with 2-3mm freezing zone (white area) around lesion for 10-30 sec
what should you PARQ pt after using liquid nitrogen
blister forms w/in hours, scab w/in a week, healing in 2-3 wks
is it okay to use liquid nitrogen straight from Dewar bottle?
NO
you can transfer HPV into container
Liquid nitrogen C/I
malignancy, Raynaud’s, sensitive skin
Electrosurgery C/I
flammable EtOH, metal implants, jewelry
**do NOT clean skin w/ EtOH - will light pt on fire!
sterile electrode with + current destroys tissue and coagulates b.v.
electrosurgery
indirect electrical current, very precise, no blood loss
electrocautery
direct, high-frequency current flows through tissue to generate heat; quick and effective with minimal blood loss
hyfrecation
complete removal of superficial lesion, both diagnostic and curative
excisional biopsy
for excisional biopsy, use ___________ and cut __________
3:1 elliptical with 30’ angle corners and #15 blade
parallel to Langer’s lines
narrow elliptic taken within a lesion to diagnose a larger lesion (biopsy)
incisional biopsy
diagnostic and therapeutic and healing is rapid with minimal scarring (biopsy)
shave biopsy
with punch biopsy, traction skin ____ to Langer’s lines, must go ____ beyond borders
perpendicular
1-2 mm
scalpels: puncture abscess, incisions, stabbing
11
scalpels: blunt dissection, excision, trimming
15
scalpels: for thick skin (back)
10
scalpels: disposable, sterile and attached to reusable handle
3
forceps that do NOT crush skin, what we use for suturing
toothed adson
forceps that do crush skin, we use for foreign body removal
toothless adson
scissors for fine dissection
iris
scissors for blunt dissection
metzenbaum
circumscribed, flat discoloration that may be brown, blue, red, or hypopigmented
macule
an elevated solid lesion up to 0.5 in diameter; color varies; may become confluent and form plaques
papule
circumscribed, elevated, solid lesion more than 0.5 cm in diameter
nodule
*a large nodule is referred to as a tumor
circumscribed collection of leukocytes and free fluid that varies in size
pustule
circumscribed collection of free fluid up to 0.5 cm in diameter
vesicle
circumscribed collection of free fluid more than 0.5 cm (5 mm) in diameter
bulla
loss of intercellular connections (desmosomes) between keratinocytes; occurs in pemphigus vulgaris and related d/o; cell shape changes from polygonal to round
Acantholysis
thickening of epidermis (squamous) layer; rete ridges usually extend deeper into dermis
Acanthosis
flat discoloration > 5 mm
patch
thickened cornified layer, often with prominent granular layer; keratin may be abnl
hyperkeratosis
either orthokeratotic or parakeratotic
exaggeration of normal pattern of keratinization with no nuclei in cornified layer
orthokeratotic
type of hyperkeratosis
type of hyperkeratosis with retained nuclei in cornified layer
parakeratotic
hyperplasia of spinosum layer; assoc. w/ hyperlipidemia, Cushing’s, DM
acanthosis nigricans
verrucas, flat, papules; “stuck on”
seborrheic keratosis
chronic scratching cz skin growth
lichenification
2’ to trauma, increase fibroblasts, brown-firm
dermatofibroma
moveable capsule filled with keratin, sebum
epidermal inclusion cysts (sebaceous)
sebaceous cyst on head
pilar cyst (wen)
subQ moveable nodule; often recur
lipoma
is it ok to perform minor surgery on hemangioma?
NO
esp. not cavernous hemangioma
dandruff, cradle cap
seborrheic dermatitis
for acne vulgaris, avoid ____ and use ______
avoid: B12, iodine
use: zinc, tea tree
rough scaling skin, SCC risk
solar (actinic) keratosis
biopsy! (to r/o neoplasm)
round/oval papules or plaques, pink/red/purplish on legs
Kaposi’s sarcoma
biopsy! (to r/o neoplasm)
elevated falt topped area, usu > 0.5 cm
plaques
“liver spots”, usually benign from excess sun exposure
solar lentigo
biopsy! (to r/o neoplasm)
lesion of subQ fat, usually anterior shins; cz by sarcoid, TB, leprosy, histoplasmosis, coccidiomycosis, Crohn’s
Erythema nodosum
biopsy! (to r/o neoplasm)
MC neoplasm, slow growing, rare Mets
BCC
fast growing neoplasm, Mets common, exposure to arsenic
SCC
pearly, rolled boarders
BCC
indurated, ulcerated/crusty, may bleed easily
SCC
MC in females, tumor marker S-100, METS!!
Melanoma
MC melanoma
superficial spreading
most aggressive melanoma
nodular
melanoma in elderly, slow growing
lentigo
MC melanoma in dark skin - palms, soles, nails; aggressive!
acral
GABHS of dermis
Cellulitis
Cellulitis can lead to
necrotizing fasciitis or erysipelas (lymph involvement, orange peel)
red streaking along LN
lymphangitis
strep infx of superficial lymphatics; usu 2’ to immunocompromised, trauma, ulcer
erysipelas
chronic venous insufficiency d/t diabetes or bed ridden
stasis dermatitis
HPV - genital warts
6, 11
HPV - dysplastic
16, 18, 31, 33
6th dz, HHV 6/7, maculo-papular rash with high fever
Roseola infantum
cranial-caudal macular-papular rash with mild fever
Rubella (German Measles)
cough, coryza, and conjunctivitis, koplick spots and cranial-caudal macular-papular rash
Measles (Rubeola)
Measles complication
subacute sclerosing panencephalitis
staph or strepB, honey colored crust
Impetigo
Impetigo tx
mupirocin
MRSA tx
mupirocin
Herpes zoster tx
Levodopa, UV light
Herpes zoster vaccine
Zostavax
viral infx; waxy, pink with small central pit; B9
molluscum contagiosum
gold with woods lamps
Tinea versicolor (pityriasis versicolor)
Vitiligo tx
copper, Vit D, phenylalanine
10-20 y/o, herald patch
Pityriasis rosea
tx for atopic derm
Psorinum (homeo), Sulphur (homeo), Vit C
symmetrical lesions with concentric rings (target lesion)
erythema multiforme
timeline of drug eruptions
1-3 weeks after (7 days MC)
*stop taking the drug!
infx of nail bed, painful swelling by staph, strep or candida
paronychia
deep infection working under nail bed
felon
Tinea unguium (nail fungus) tx
Melaleuca alternifolia
+Nikolsky sign, blister spreads, AI, DEADLY
pemphigus vulgaris
bx: intra-epidermal bullae with anti-epithelial cell Abs against desomsomes (AKA anti-desmoglein-3 antibodies)
pemphigus vulgaris
bullae intact in subepidermal space, flexors/trunk
Bullous pemphigoid
less serious than pemph. vul.
bx: epidermal blisters and anti-basement membrane auto IgGs
Bullous pemphigoid
dermatographism is seen in what immunologic condition
urticaria
cz of erythema multiforme
HSV and Mycoplasma pneumonia
DDx SJS
flu-like sx followed by painful red or purplish rash that spreads and blisters; top layer of affected skin dies and sheds
Stevens-Johnson Syndrome
usu. a rxn to a medication or infx
Bull-s eye, B. Burgdorferi, ixodes ticks
erythema migrans
measles-like maculopapular rash
morbiliform drug eruption
discoid or malar rash, < sun exposure, IgG/IgM
Lupus erythematous
small flesh papules, increase in size on hands and feet
granuloma annulare
IgA deposits cz pruritic papules/vesicles; assoc. with celiac dz
Dermatitis herpetiformis
Kobner’s phenomena
psoriasis
Auspitz phenomena
psoriasis
bx: mounds of parakeratosis with neutrophils, diminished or absent stratum granulosum, epidermal thickening
psoriasis
malar rash with pustules/papules on an erythematous base with telangiectasia; < stress, hot/cold, food triggers
Rosacea
red, scaling with prominent skin lines - itching constantly
Lichen simplex
Wickham striae, 5 P’s on palms and wrist; assoc. w/ Hep C
Lichen planus
white, painless patches on tongue that canNOT be scraped off; cz by EBV, usu. in HIV pt.
Hairy leukoplakia
may need to bx
Neurotoxic, painless spider bite
Black widow
Necrotoxic, painful spider bite
Brown recluse
serpiginous lesions, < night, doesn’t go above neck
Scabies
