Minor Surgery/Derm Flashcards
Describe a needle driver
Blunt
Shorter/wider than forceps/hemostats
Toothed or smooth (toothed = better grip but can damage sutures)
Tungsten carbide (better grip than smooth, less damage than toothed)
Describe the difference between the types of scissors:
Iris
Metzenbaum
Bandage
Iris - fine dissection, suture removal IF no suture scissors
Metzenbaum - blunt dissection, gauze cutting
Bandage - curved tip; cuts bandage without damaging tissue underneath
Differentiate adsons forceps with and without teeth
Adsons with teeth - handling tissue
Adsons without teeth - grasping sutures, foreign bodies, picking things up steriley (do NOT use on tissue; compression injury risk)
Describe the difference between curved and straight hemostats
Curved - undermining
Straight - clamping (usually BVs)
Describe the function of the following scalpel blades
#3, #11, #15, #10
3 - disposable scalpel blade attaching to reusable handle
#11 - puncture abscesses, incisions, stabbing
#15 - blunt dissection, excision, trimming, elliptical biopsy
#10 - blunt dissection + excision on thick skin
With sutures, more zeros = ____ thread
Finer
Smaller size = less tensile strength
Explain the differences between braided and monofilament sutures
Monofilament - single thread; passes through tissue easily, less tensile strength
Braided - three threads braided, secure, easier to tie, but more likely to lead to infection
What are absorbable sutures used for? What are the different types?
Deep tissue layers
Natural - digested by body enzymes - MORE likely to cause a reaction than synthetic
Synthetic - hydrolyzed
What are the types of natural absorbable sutures?
Both are monofilament
Plain catgut - more tissue reactivity, half life 7-10 days
Chromic catgut - less tissue reactivity (chromic = salt that delays absorption), half life 2-3 weeks
What are the types of synthetic absorbable sutures?
Polyglactin (vicryl) - monofilament and braided, half life 2-3 weeks
Poly glycolic acid (dexon) - monofilament, half life 2-3 weeks
Polydioxanone (PDS) - monofilament, half life 4-6 weeks
Natural sutures are ____ likely to cause a reaction than synthetic
More
What are the types of natural non-absorbable sutures?
Silk: braided, high tissue reactivity
Polyester/polybutester: high tissue reactivity
What are the types of synthetic non-absorbable sutures?
Nylon/ethilon: monofilament, low tissue reactivity
Polypropylene/protene: monofilament
For the following area of the body, list the skin suture size and time of removal
Face/neck
5-0, 6-0
Removal in 3-5 days
For the following area of the body, list the skin suture size and time of removal
Arms/hands
4-0, 5-0
Removal in 7-10 days
For the following area of the body, list the skin suture size and time of removal
Trunk, legs, feet, scalp
3-0, 4-0
Removal in 7-14 days
High tension areas would have ____ removal times
Longer; 10-14 days
Risks of leaving sutures in too long AND taking them out too soon
Taking out too soon - dehiscence (splitting)
Leaving too long - inc risk scarring
Describe the following stitch type, including what it may be used for or risks
Simple interrupted
Can cause “railroad track” scar
Describe the following stitch type, including what it may be used for or risks
Vertical mattress
Better for everting skin edges
Good for wounds under tension
“Far far near near”
Describe the following stitch type, including what it may be used for or risks
Horizontal mattress
Used for high tension wound support
Holds fragile skin together
Distributes tension
Describe the following stitch type, including what it may be used for or risks
Deep or buried
Decreases tension in larger, deeper wounds
Knots are inverted below skin margins
Describe the following stitch type, including what it may be used for or risks
Intradermal/subcuticular running
In dermis, not visible
Better cosmetic appearance
Best in wounds with less tension
Describe the following stitch type, including what it may be used for or risks
Continuous running stitch
Not cosmetic
Less secure
Difficult to remove
Describe the following stitch type, including what it may be used for or risks
Three point/half buried mattress
V shaped wounds so not to impair blood flow to tip
Describe the following needle types:
Conventional cutting
Reverse tying
Tapered
Conventional - cosmetic surgery
Reverse - most common; skin, tendon sheath, oral mucosa
Tapered: pierces tissue without cutting; fascia, muscle, myocardium, bowel
Explain the following methods of skin closure including indications, advantages/disadvantages
Steri strips
Dermabond
Staples
Steri-strips:
-small wounds, thin flaps, in kids
-with sutures with difficulty everting edges/high tension areas
-sticker with benzoin
-cant be used around digits (tourniquet effect)
Dermabond:
-cyanoacrylate tissue adhesive
-sterile, nontoxic
-50 sec to set, wound heals 5-10 days
-cant be used in areas of excessive motion/moisture (knees, elbows, hands/feet, mouth, groin)
Staples: low risk of infection
What is the MOA of local anesthetics?
Block Na reputable to prevent depolarization of pain stimuli
List the order in which sensation is lost AND the order in which it returns with use of local anesthetics
Lost:
Pain
Temp
Touch
Deep pressure
Motor
Returns in reverse order
Describe the type of administration and uses of anesthetics:
Local
Field block
Regional/nerve block
Local - subQ injection (lacerations, small lesions)
Field block - circle around operative site (I&D, complex lacerations)
Regional/nerve block - directly into/near group of nerves
Describe the angles for IM and SQ injections
IM = 90 deg
SQ = 30-45 deg
What are amides use in minor surgery? How are they metabolized? Allergies to them are ____
Anesthetics; metabolized in liver by microsomes enzymes
True allergies are rare
What are the topical amides?
Lidocaine
EMLA cream
What are the infiltrative amides?
Lidocaine/xylocaine
Bupivacaine/marcaine
Mepivacaine/carbocaine
Describe the time of onset, duration, dosing, and adverse reactions of the following infiltrative amide:
Lidocaine/xylocaine
1-10 min onset
30-60 min duration
10 cc of 1% > 100 mg (add a zero to cc for dose)
AE: drowsiness, caution in elderly, may cause heart block and arrythmias
Max dosing (for 90 min to 2 hour intervals)
-Child: 3.3-4.5 mg/kg, dont exceed 75-110 mg
-Adult: 4.5 mg/kg, don’t exceed 300 mg
Describe the time of onset, duration, dosing, and adverse reactions of the following infiltrative amide:
Bupivacaine/marcaine
8-12 min onset
3-4 hr duration
AE: cardiac complications; NO IV due to heart block of long duration!!
Max adult: 4 mg/kg of 0.25%, not to exceed 200 mg
Describe the time of onset, duration, dosing, and adverse reactions of the following infiltrative amide:
Mepivacaine/carbocaine
8-12 min onset
2-2.5 hr duration
Max adult: 5 mg/kg of 1%, not to exceed 400 mg
What is an ester in minor surgery? How is it metabolized? Allergies are ___
Anesthetic; metabolized in peripheral plasma by psuedocholinesterase
More allergic reactions than amides
What are the topical esters?
Benzocaine - poorly observed, need at least 10%
Proparacaine - opth; <1 min onset, 15 min duration
Cocaine: ENT; <1 min onset, 1 hr duration
Tetracaine (TAC), epi, cocaine - FAST
What are the infiltrative esters?
Procaine/novocaine: slower onset but same duration as lidocaine
Allergic reactions common
What are types of adverse reactions that can occur with anesthetics?
Toxic if injected IV or excessively > hypotension, bradycardia, cardiac arrest (tx with O2)
Allergic - anaphylaxis rare, tx with Benadryl and epi/o2, more common with esters
Autonomic: tachycardia, sweating, dizziness, syncope (tx generally not needed) ** most common adverse reaction, have pt lying down prior to injection to prevent**
Guidelines to reduce pain of administration of anesthetics
Inject slowly
Administer with 27-30 g needle
Keep at room temp
Rinse wound with anesthetic first
Combine with sodium bicarb (10 cc 1% lidocaine: 1 cc 8.4% Na bicarb)
Role of epinephrine in minor surgery including benefits, adverse effects, max dose, and CI
Advantages: dec bleeding, prolongs duration of anesthetic, dec toxic reaction via vasoconstriction
AE: anxiety, tremors, palpitations, tachycardia
Max dose 0.2 mg
Avoid in MAOis, TCAs, thyrotoxicosis, severe CVD
Avoid in end areas (ear, nose, fingers, toes)
What is the difference between sterilization, disinfection, disinfectant, and antiseptic?
Sterilization - desctruction of all living microorganisms, including bacterial spores
Disinfection - reduction of a population of pathogenic microorganisms without achieving sterility
Disinfectant - germicidal substance used on INANIMATE objects to kills pathogenic microorganisms, but not necessarily all other
Antiseptic - chemical agent applied TO THE BODY that kills or inhibits growth of pathogenic microorganisms
What b vitamin is good for acne?
Niacinamide (B3)
Which of the following is CI for shave biopsy?
Hyperpigmented moles > 1 cm
Molluscum contagiosum
Seb keratoses
Benign superficial lesion
Hyperpigmented moles; BM unlikely to be visualized, so def dx unavailable (also most likely to be cancerous)
Avoid shave biopsy as dx; its more cosmetic
Which of the following is metabolized in the liver?
Lidocaine
Epi
Cocaine
Procaine
Lidocaine
Which is primary metabolized by plasma enzymes?
Lidocaine
Procaine
Epi
EMLA
Procaine > metabolized to PABA in peripheral tissues and plasma
10 cc of a 1% solution of lidocaine contains ____ mg
100 mg
1 cc of a 1% lidocaine solution contains ___ mg
10 mg
How to go from __cc of 1% solution > __ mg
Add a zero to cc (% > mg/mL)
Ex: 10 cc of 1% = 100 mg
Indications for adding epi to local anesthetics include all of the following EXCEPT
Decrease oozing
Prolong duration of anesthetic
Reduced risk in pts with severe CVD
Decreased risk of toxic rxn by reducing circulating levels of local
Reduced risk in severe CVD
Which of the following is a sign of local anesthesia CV toxicity?
Shivering
Hypotension
Syncope
Sweating
Hypotension
Which of the following is the best tx for a toxic reaction/systemic toxicity?
Epi
Benadryl
Lidocaine
Oxygen
Oxygen
which of the following is an indication for a NON-absorbable DEEP suture?
Tendon repair
Ophthalmic surgery
Deep skin wounds
Obstetrics
Tendon repair
Which of the following suture types has the highest liklihood of tissue reaction?
Chromic gut
Nylon
Vitro
Proline
Chromic gut
Which of the following sutures is the finest (has smallest diameter)?
5/0
000
4-0
6/0
6/0
Nylon is what type of suture
Absorbable, natural
Absorbable, synthetic
Non-absorbable, natural
Non-absorbable, synthetic
Non-absorbable, synthetic
Four cardinal signs of slight finger flexion, fuse form swelling of finger, pain on passive/active extension of the finger, and tenderness along the tendon sheath into the palm indicate:
Purulent tenosynovitis (can lead to nec fasc; refer to ortho surgeon)
CI to I&D include which of the following:
Fluctuant abscesses
Recurrent abscesses
Infected puncture wounds
Foreign bodies
Recurrent abscesses
All of the following may increase the amount of time it takes a wound to heal EXCEPT:
Hematoma
Accurate wound approximation
High tension
Dead space
Accurate wound approximation
This surgical tool is best for larger, thick, and tough skin on the back:
Iris scissors
#10 blade
#11 blade
#15 blade
10 blade
Which of the following scalpel blades has a straight and pointed cutting edge and is used to stabbing and incising the skin in I&D?
#11
#3
#10
#15
11
Which type of suture has less resistance as it passes through tissue and is less likely to harbor microorganisms? It also ties easily but knots may slip and break easily.
Catgut
Silk
Nylon
Braided vicryl
Nylon (like fishing line, strong but slippery, goes through nice but likely to have ties slip out)
What is hemostasis?
disruption of BVs, extravasation of blood consistent, initiation of the coagulation cascade, and formation of a fibrin clot
Wounds that are too contaminated to close initially but may be closed after 3-4 days post tx:
Primary Intention
Secondary intention
Tertiary intention
Quartiary intention
Tertiary intention
This stitch is great for everting skin edges and precise approximation of wound edges with little tension:
Simple interrupted
Vertical mattress
Subcuticular running
Continuous running/baseball
Vertical mattress
This easy and most versatile stitch can cause “railroad track” scarring
Simple interrupted
Vertical mattress
Subcuticular running
Half buried mattress
Simple interrupted
Urea paste dissolution and anti fungal oral meds are appropriate tx for
Keloids
Papillomata
Onychomycosis
Plantar warts
Onychomycosis (terbinafine)
Simple rupture by pressure, simple aspiration, and surgical excision are all potential tx for:
Ganglion cyst
Epidermis cyst
Trichlemmal cyst
Wen
Ganglion cyst
All of the following are variables that demonstrate amount of time to leave sutures in EXCEPT:
Universal precautions
Type of suture
Tensile strength
Potential for scarring
Universal precautions
Which of the following is a nutrient known to promote wound healing?
Vit K
Bromelain
Molybdenum
Silica
Bromelain
The most common organism causing wound infections is
Candida
Staph
Neisseria
HBV
Staph
Which of the following is a non-absorbable monofilament?
Catgut
Silk
Vicryl
Steel
Steel
in order to remove stitches, cut ____ (under/over) the know as ___ (close to/far from) skin as possible and pull the stitch out, drawing wound edges ___ (together/apart)
Under the knot, as close to skin as possible, pull stitch out pulling wound edges together
Causes of hematomas include:
Infection
Poor hemostasis
Elimination of dead space
Anesthesia
Poor hemastasis
This regional nerve block is injected into the anatomical snuff box to provide anesthesia to the lateral aspect of the proximal thumb
Radial
This regional nerve block is useful for providing anesthesia to the tip of the little finger
Ulna
Indications for hyfrecation include:
Bloody fields
Basal cell carcinoma
Actinic keratoses
Recent changing nevi > 1 cm
Actinic keratoses
Elliptical excision should have a length to width ratio of _____ with corners at ___angles
3:1, 30 deg
Elliptical excisions should ideally be made with a #____ blade, initially cutting ____ to the skin
15, perpendicular
Most dangerous of the malignant skin tumors
Malignant melanoma
Cellulitis involves what layers of skin? What is the most common bug to cause cellulitis? How is diagnosis done?
Dermis and subcutaneous tissue
Group A BH strep or staph A
Clinical dx, culture
What is a dangerous complication of cellulitis?
Necrotizing fasciitis
What is erysipelas? What is the common bug and how does it present/
Superficial cellulitis involving lymphatics
Group A BH strep pyogenes
Painful, raised, and sharply demarcated “orange peel” lesion with fever, malaise, local lymphadenopathy, and possible streaking
May present similar to impetigo but impetigo has NO systemic sx associated
What is lymphangitis?
Red streaking along lymph tract (from infected area to armpit/groin)
Throbbing pain
Fever/chills
Myalgia
HA
Loss of appetite
- sign a bacterial infxn is worsening
What HPV strains most commonly cause genital warts? What is the name for this pathology?
6 and 11
Condylomata acuminata
What HPV strains cause flat warts and are more likely to lead to cervical dysplasia?
16, 18, 31, 33
What is impetigo? How does it present, and how is it dx
Skin infxn caused by bacteria (strep pyogenes and/or staph a)
Pruritic pustules, vesicles, bullae, with “honey colored” crust
Dx: clinical, culture, or gram stain
Molluscum contagiosum etiology
Children, Immunocompromised
Virus
Name the pathology: Epithelial flesh papules > dome gray/brown hyperketatotic growths with black dots on surface
Verruca vulgaris (common warts) caused by HPV
What is Tinea incognito?
When the clinical appearance of Tinea changed because of inappropriate tx
Tinea versicolor etiology and presentation
Chronic yeast overgrowth in skin inc by heat; pityrosporum obiculare
Not contagious
White/brown/pink scaling oval patches on trunk
Vitiligo is associated with increased risk of what pathologies?
Other autoimmune disorders (thyroid, pernicious anemia, Addison, alopecia areata)
What is pityriasis alba and how does it present? What would be your ddx?
Children and young adults; round/oval slightly elevated fine scaling plaque that leaves hypopigmentation on face, neck, arms
Ddx: vitiligo and Tinea versicolor however those both appear white. In vitiligo, borders are distinct. Tinea versicolor rare on the face. KOH will differentiate the three.
What is pityriasis rosea? How does it present?
Teens and young adults
No known cause; linked to mycoplasma, picornavirus, and human herpes virus 7
“Harold patch” (plaque) precedes eruption followed by smaller plaques that follows long axes parallel lines of cleavage starting at spine (Xmas tree pattern)
Self limited
What is acute paronychia? Presentation, tx, and complications
Painful bright red swelling of proximal and lateral nail fold; chronic type associated with contact w water
Tx: keep hands dry, avoid lotions/ointments
Early: warm soaks
Late: if pus - I&D with #11 blade or needle (blade between nail and nail fold) abx
Separation of nail plat (onycholysis) may predispose to pseudomonas infxn
What is a felon?
Deeper infection working its way into/under the nail bed and to fat pad
Abscess formation usually due to staph in distal pulp of finger involving multiple septae and compartments; can cause rapid and significant destruction (necrosis) and osteomyelitis
Tx of Tinea unguina
Oral fluconazole or itraconazole
How to differentiate Tinea unguina and psoriasis on the nails
Pitting not found in Tinea
describe the presentation of infestation/bite with the following:
Black widow
Strong Neurotoxin: intense pain in regional nerve, spread outward
Starts 10 mins after bite
Original bite is painless
describe the presentation of infestation/bite with the following:
Brown recluse/fiddle back
SE US
Necrotoxic - sphingomyelinase D
Painful bit
Turns red > swells > dusky > necrotic over 7 days > eschar sheds in 3 weeks
HA, fever, diffuse rash
Tx for brown recluse bites
Wound care, IMMEDIATE steroid administration to prevent skin from melting/skin grafts
describe the presentation of infestation/bite with the following:
Scabies-mites
Very pruritic, esp at night
Red papules, excoriations, burrows
Hands, wrists, elbows, axilla, umbilicus, groin/penis
Contagious
Takes 6 weeks to show after exposure
Tx scabies
Elimite, neck down x 8 hours
Flea vs chiggers bites
Chiggers bite in 3s where clothes dont cover (waist, socks, ankle)
Fleas - ankles, after animal is gone, can be dormant for 1 year
etiology, changes/risks of junctional nevi
Junctional-macular
Hereditary/sun exposure determine # of moles
>50 inc risk of melanoma
As moles age, raise up, and loose color = normal change
etiology, changes/risks of congenital nevi
Present at birth and grow
May thicken and develop hairs
Larger/darker
10 cm have a 10% MM risk
Excise at puberty
etiology, changes/risks of Actinic keratoses/solar keratoses
Rough scaly spots on sun-damaged skin (face, forearm, hand)
Can give rise to SCC
etiology, changes/risks of Seborrheic keratosis
Greasy, scaly, verrucous flat papules to plaques
“Stuck on” appearance
Occur more in sun exposed areas
Can get inflamed and simulate a skin CA
etiology, changes/risks, and tx of Dermatofibroma
Overgrowth of fibroblasts + BV
Usually brown and firm (feels like a BB under the skin)
Secondary to trauma
LEs, women
Feel like lentils under skin
Leave alone. Elliptical excision
etiology, changes/risks of Epidermal inclusion cysts (sebaceous cysts)
Movable skin colored papules/nodules
SubQ
Face, back, ears, groin
Sack of epidermis under skin filled with keratin/sebum
Smell
Can get inflamed, usually not infected
Tx of epidermal inclusion/sebaceous cyst
Incising and blunt dissection around capsule or it will return
etiology, changes/risks of Pilar cysts (wen)
On scalp, subQ movable nodule
Have firmer keratin than EIC/no smell
Usually pop out during surgery
Types of hemangiomas
Capillary - affect BVs in uppermost layers of skin (strawberry, superficial angiomatous nevi)
Cavernous (subQ angiomatous nevi, more deeply set in dermis and subcutis)
Cherry - midtrunk, inc after 40, can be removed with diathermy/laser
etiology, changes/risks of Seborrheic dermatitis
Chronic superficial inflammatory process of hairy regions of the body triggered by stress, fatigue, change of season, of reduced general health
Pityriasis capitis (dandruff)
Cradle cap (thick, yellow, crusty scalp lesions in infants)
Proliferation of pityrosporum ovale (yeast)
General rules for skin neoplasia and ND scope of practice
If you don’t know what a lesion it > biopsy it
If you have ANY suspicion it is neoplastic send them right to derm; delay from biopsy to tx can cause Mets
If you know its neoplastic you are NOT LEGALLY ALLOWED to perform minor surgery on it
Always err on cautious side!
etiology, changes/risks of Lentigo (“Spots”)
Maligna
Benina
Precancerous
etiology, changes/risks of BCC
Most common skin CA
Slow growing; bleeding or scabbing sore than heals and recurs
Rare Mets
Nodular; often face, small translucent papule or nodule that appears “pearly” with rolled edges and may be pigmented with small BV or red
etiology, changes/risks of SCC
Faster growing, indurated, ulcerated/crusty
Second most common skin CA
Bleeding, friable surface
Very metastatic
Areas of sun exposure
RF: arsenic exposure, burn scars, radiation, trauma, tobacco, alcohol
Ddx: trichoepithelioma
What are the 6 key risk factors that make someone high risk for melanoma?
Fhx in 1st degree relative
Fair skinned, red/blonde, blue eyes
Marked freckling of upper back
AK
3+ blistering sunburns prior to age 20
3+ years with outdoor summer jobs as a teen
4 types of malignant melanoma
Superficial spreading
Nodular
Lentigo maligna
Acral
Describe superficial spreading MM
Most common
Radial phase before invading dermis
Describe nodular MM
Most aggressive
Skips radial phase, goes straight to vertical
Describe Lentigo maligna MM
Elderly
Sun exposed areas
Occur in large Lentigos (age spots)
Occur slowly over 20 years
Describe Acral MM
Most common in darker skinned ppl (black, Asian, hispanic)
Occur on palms, soles, nail beds
Aggressive and overlooked
At what diameter do moles become concerning for malignancy?
> 6 mm or a pencil eraser
Describe presentation and work up for pemphigus vulgaris
Middle aged/elderly
Rare, AI
Intra-epidermal blisters (vesicles and bullae) that move into painful erosions, randomly scattered
Nikolsky sign (w/ pressure, blister spreads)
Lab: microscopy, IF; shows IgG in skin and serum
What is cholinergic urticaria?
From overheating, exercise, emotional stress
Start in few mins, last 30 min
What types of ddx would you be considering in both acute and chronic urticaria?
Acute: bacterial, viral infxns, drugs (aspirin, abx)
Chronic: rule out internal dz (thyroid, CA, lupus), infections, ingestants (foods, drugs, dyes, dust, mold, pollen)
Describe presentation and work up for Erythema multiforme
Acute illness; hypersensitivity, drugs
Round lesions on forearms, hands, knees, or feet that look like a target with a fluid filled blister inside
Common, self limited
Dx: clinical or biopsy
What would the presentation looked like of a drug eruption? What is the most common variety?
Onset within 1 day to 3 weeks of drug therapy (depends on prior sensitization)
Urticarial is most common, eczema may be in Ddx but would itch much more severely than a drug rash
What is the etiology of urticarial (hive) drug reaction?
may be IgE mediated, triggering mast cell granule release, or drug may directly cause mast cell granule release
Describe a morbilliform drug eruption
Maculopapular/exanthematous drug eruption
Looks like measles rash; symmetrically distributed on the trunk and proximal extremities
Bright pink macules and slightly raised papules
What is a fixed drug eruption? What are drugs that are common culprits of this type of rxn?
Occurs at same sites with each episode
OTC drugs containing phenophthalein, pseudoephedrine, etc
Tetracyclines, barbiturates, phenothiazines, sulfonamides
Oval, itchy, burning dusky red plaque
What is the presentation and etiology of toxic epidermal necrolysis (TEN)/Steven Johnson syndrome (SJS)?
Severe life threatening blistering disorder that presents with fever, pruritis, conjunctivitis, and erythema-multiforme rash sometimes (commonly affects mucous membranes/ENT) > progresses and melts skin through dermis
30% fatal
Almost ALWAYS due to a drug rxn
Tx for TEN/SJS
Emergent referral
Electrolyte replacement
Possibly high dose IV steroids
Etiology and presentation of discoid lupus erythematosus
Chronic recurrent AI disorder primary affecting the skin
Unknown etiology; IgG and IgM deposited in skin
Exposure to sunlight frequently precedes lesions
More common in women (10x), onset in 30s
Work up for discoid lupus erythematosus
Clinical dx - no anemia, normal ESR, ANA absent or low (not SLE), anti DNA absent
Describe presentation and work up for Granuloma annulare
Ring of small, firm, flesh colored or red papules on lateral or dorsal surfaces of hands and feet
Begins with asx papule that undergoes central involution > inc up to 5 cm over months
Spontaneous involution or lasts for years
Histology shoes collagen degeneration
Tx granuloma annulare
Intralesional injections with triamcinolone
Atopic dermatitis major criteria
Pruritis
Flexural lichenification and linearity in adults
Facial and extensor involvement in babies/kids
Chronic or chronically relapsing dermatitis
Personal or fhx atopy
Lab / work up atopic dermatitis
Serum IgE > 200 IU/mL
Eosinophilia
Presentation / etiology psoriasis
Red, scaly-white papules and plaques; removal of scale > blood drops (Auspitz)
Triggers: emotional stress, trauma to skin (koebners phenomenon), strep throat (guttate)
Describe presentation and work up for Rosacea
In adults, men > women
Two components: redness/flushing/telangiectasia/burning
Papules/pustules
No comedomes
Mid face, around eyes
Unknown etiology; triggers can be emotional stress/ppl who blush, hot/cold air, exercise, cheese/wine/coffee
Describe presentation and work up for lichen simplex
Itch/scratch cycle > lichenification
Describe presentation and work up for Lichen planus
palms, wrists
Pruritic
Polygonal
Purple/pink
Planar
Plaques / Papules with
wickhams striae (criss cross white lines)
What are the sx and types of kaposi sarcoma?
Sx: purple, red, brown blotches
Types:
Classic
Endemic
Immuno suppression related
Epidemic kaposi sarcoma
Describe classic kaposi sarcoma
Slow growing
Common in old M
Leg lesions
Describe endemic kaposi sarcoma
Common in young M
Often aggressive
Describe immuno suppression related kaposi sarcoma
Mostly affects skin
Organ transplant pts
Describe epidemic kaposi sarcoma
Seeds in AIDS pts
Affects multiple areas of the body
What is the difference between a carbuncle and a furuncle? How do you tx them?
Furuncle (boil): pus filled infection hair follicle
Carbuncle: cluster of connected furuncles
Tx: I&D, abx, warm compress
What is cimicosis?
Bed bugs
What are the common bugs and tx for acute and chronic paronychia?
Acute: staph A (cephalexin)
Chronic: candida (antifungals)
Before minor surgery procedures, you ________ (should/should not) shave hairy areas
Should NOT
How to prepare the field for a closed site?
Use antiseptic over site (10% povidone-iodine (betadine) or 0.4% chlorhexidine gluconate) and leave sitting for 2 mins
How to prepared the field for an open wound?
Irrigate with normal saline (35 mL syringe with 19 g needle)
Use betadine around the wound on the intact skin
Should you use betadine, hydrogen peroxide, both, or neither on an open wound? Why or why not?
NEITHER
They will cause delayed wound healing and organic material neutralizes the antiseptic activity
Hydrogen peroxide is also toxic to healing wound due to disruption of new epithelium
What are methods of sterilization/disinfection of tools?
Alcohol (70%) / chlorhexidine (5%) - emergency disinfection in 2 mins; does NOT sterilize
2% glutaraldehydes - disinfection of choice; disinfects after 10 mins, sterilizes after 10 hrs, low tissue toxicity
Boiling - 100 c for 5 min (disinfect) - 30 min (sterilize); only use if no other option
Dry heat - 160 c for 60 min (not for rubber, plastic, cloth, or paper)
Autoclave - method of choice bc efficient and reliable. 15 PSI @ 121 c for 30 mins
What are important considerations for documentation?
For puncture wounds, document tetanus status
Describe neurovascular status and tendon function
CI to performing minor surgery/instances to refer
Cut tendons, nerves
Cosmetically significant facial wounds
Foreign bodies deeper than fascia or near critical structures
Deeper than fascia/muscle
Eyes, nose, axilla, groin, post triangle of neck
Young children
Serious systemic illness
Pt known to form keloids
Bleeding risk (extended bleeding time, pulsating lesion, large size/compromised blood supply)
Types of cryotherapy
Histobreeze (-50c) - compressed gas in aerosol can
CO2 slush (-78.5c) - simple, cheap, not effective
Nitrous oxide (-89.5c) - expensive, stores indefinitely
Liquid nitrogen (-196c) - effective; swab, cryoprobe
Technique cryotherapy
Freeze zone of 2-3 mins
Continue to maintain frozen zone x 10-30 secs, thaw, then repeat
Blister > scab > sloughs; heals in 2-3 weeks
Advantages and disadvantages of cryotherapy
Advantages: minimal scarring, infections rare, no dressing, no anesthetic
Disadvantages: depigmentation, caution on thin skin, HPV not killed by freezing
Indications for cryotherapy
Warts, Molluscum contagiosum, skin tags, granulation tissue, AK, Sebb keratosis, small nevi, cervical dysplasia
Electrosurgery types & uses
Electrocautery - indirect current (hemostasis, skin tags, subunguinal hematomas, removing benign lesions with curettage)
Hyfrecation - direct current (hemostasis, warts, small nevi)
Advantages and disadvantages of electrosurgery
Advantages: quick, eff, less blood loss
Disadvantages: lesion is destroyed
CI electrosurgery
Metal pins, pacemaker
Don’t use antiseptics (flammable)
What type of biopsy is indicated for an epidermal lesion
Shave biopsy
What type of biopsy is indicated for an Intradermal lesion
Excisional, punch, or incisional
What is an excisional biopsy?
Complete removal of the lesion; both diagnostic and curative
Steps for an elliptical biopsy
Orient resting skin tension lines
Administer field block
Prep with betadine
Excise with #15 blade - cut perpendicular to the skin and apply tension during
Immediately place in 10% formalin
Control bleeding (gauze, pressure, electrocautery)
Undermine lateral edges to reduce tension
Close would and cover with dry, sterile dressing
Ratio / degrees for elliptical biopsy
3:1 ratio with 30 degree corner
What is an incisional biopsy and what are indications for using this type? What are disadvantages?
Specimen is taken from within a lesion; used to dx a large lesion
Disadvantages: may miss malignant area; bleeding, scarring
Indications for punch biopsy
Small/benign nevi
Inflammatory skin disorders (dermatitis, vasculitis, CT disorders)
Indications and CI shave biopsy
Superficial lesions
NEVER use on lesion that might be melanoma
Anesthetize under lesion to raise up
Steps for cyst/lipoma removal
Prep, anesthetize
Make linear incision over center following RStLs
Using blunt dissection, “shell out” lipoma + capsule (for cyst keep capsule intact to prevent recurrence)
If tethering vessels on deep surface, ligate with absorb suture
Probe open wound to ensure no remaining lobes
Close dead space and skin
Steps for toenail removal
-Prep liberally with betadine
-Web space block with 1-2% lidocaine (NO EPI)
-Exanguinate toe by wrapping with sterile gauze then with a rubber band
-Penrose drain or rubber tournaquet, clamp with Kelly clamp (dont leave on more than 15-20 mins)
-cut narrow strip of nail all the way to nail matrix, grasp with clamp and gently remove with rotation/traction (make sure entire nail with root is removed)
-dress with Vaseline gauze then wrap with dry gauze
-advise pt to elevate foot rest of day
Describe primary method of closure and when its used
Immediate suturing of a wound
Use: clean wounds
Don’t suture wound if >8-12 hr old
Describe tertiary method of closure and when its used
Delayed primary;
Visibly contaminated wounds
Irritgate, debride, and pack
In 3-4 days can close primarily
Eg: dog bite
Describe secondary intention method of closure and when its used
Contaminated or infected wounds, wounds with significant tissue loss, devitalization
Left open to heal
What is the purpose of an occlusive dressing?
To allow sweating but keep bacteria out
Wounds re-epithelialize faster in _____ (moist/dry) environment
Moist
explain how to dress surgical wounds
Clean/sutured wounds only need simple/dry dressing
Use non stick gauze (e.g.tefla), then gauze, then tape
Post-procedure instructions
Keep dry 24-48 hours
Digit/extremity sites should be elevated
Monitor for signs of infxn
Redress every 2-3 days
Suture removal with iris scissors or #11 scalpel
Complication possibilities with procedures
Infection
Hematoma
Dehiscence
Scarring
The most common cause of delayed wound healing is _____
Infection
Common organisms for wound infection, presentation, and tx
MS: staph A
Other: strep, staph epi, E. coli, proteus, nitro bacteria, klebsiella, candida
Signs of infxn onset in 4-10 days
Tx: culture > abx
If prurulence is seen, remove sutures and allow wound to heal by secondary intention
Hematoma presentation, causes, and tx
Collection of blood in tissues can lead to > infection, dehiscence
Presents within 24-72 hours
Causes: lack of hemostasis, pts at risk include those on NSAIDs or anticoagulants
Tx:
Small - warm compress
Large - reopen and establish hemostasis, heal by secondary intention
Wound dehiscence presentation, causes, and tx
Separation of wound edges caused by infection, hematoma, inadequate undermining/excessive tension, poor suture technique, excessive pt activity, removing sutures too soon
Tx: tx underlying cause
If within first 48-72 hours, re-suture
If over 72 hours: heal by secondary intention
Hypertrophic vs keloid scars
Hypertrophic: MC, does not involve any previously uninjured tissue
Keloid: continue to enlarge beyond original dimensions of wound in pseudo tumor fashion
Name the stages of healing and when they occur
Hemostasis (coagulation)
Inflammation (immediately: days 1-4)
Proliferation (granulation) 3-21 days
Remodeling 3 weeks - 6-18 months
What is hemostasis?
Formation of a fibrin clot
When in wound healing does inflammation occur? What are the steps?
Begins immediately; days 1-4
Platelets secrete cytocytes, clot formation triggers complement cascade
Neutrophils in 5-6 hr, last 3-4 days
Macrophages transition inflammation > repair and phagocytize
Re-epithelialization: basophils migrate within 24-48 hours
New keratinocytes proliferate 1-2 days after injury
When in wound healing does proliferation occur? What are the steps?
Proliferation (granulation) - 3-21 days
New capillaries surrounded by fibroblasts form granulation tissue; angiogenesis brings oxygen and nutrients
When in wound healing does remodeling occur? What are the steps?
3 weeks to 6-18 months
30-40% strength by 3-4 weeks
80% at one year
Contraction is normal due to myofibroblasts ad orientation of collagen. Contracture is abnormal formation of tight scar due to excessive contraction
Common nutrients for wound healing
Vitamin C: promotes collagen formation
Zinc: collagen synthesis, cross linking, immune function
Copper: collagen cross linking
Vit E: reduce scar formation
Flavonoids: reduce scar formation
Causes of chronic paronychia
Fungal infxn
Retained foreign body
In terms of abscesses, in what scenarios would you refer?
Recurrent
Severe DM
Immune def
Bleeding disorder
What is a dermoid cyst?
Collection of tissue under skin; may contain hair, teeth, or nerves
What is a Epidermis cyst?
Contains dead skin cells
What is a Sebaceous cyst?
Filled with yellowish material
On scalp is a Pilar (wen) cyst
What is a Trichilemmal cyst?
Filled with keratin
Also called Pilar cyst
What is an acrochordon? How do you tx it?
Skin tag; shave or lift and snip. Electrocautery
What is a Cutaneous horn? How do you tx it?
Protrusion made of keratin, shave or freeze
What is a Keratoacanthoma? How do you tx it?
Rapid growth, light exposed skin, round with rolled edges and central keratin plug
Diff to distinguish between BCC, base may contain SCC
Refer or excision with biopsy
What is a Lentigne?
Liver spot
Benign and from sun exposure
Tx Molluscum contagiosum
Cryo, salicylic acid
Tx nevi (junctional, compound, Intradermal)
Large: elliptical excision
Small: punch biopsy, curette/cautery, cryo, hyfrecation/dessication
What is a Dysplastic nevus? How do you tx it?
features between benign nevus and malignant melanoma
Possible melanoma precursor; probably marker for inc risk
Refer to specialist for surveillance
What is a Pyogenic granuloma? How do you tx it?
Common benign inflammatory masses of BVs and fibroblasts
Erupt rapidly, usu due to trauma/infxn (lips, tongue, palms)
Cryo, curette/cautery, excision if want to send to path
What is sebaceous hyperplasia?
Enlarging of sebaceous glands; occurs with age
How do you tx telangiectasia?
Tx for cosmetic purposes
Hyfrecation, electrocautery (touch the central vessel)
Tx for verruca
Duct tape, salicylic acid, podophylin, thuja, tea tree oil
Then > cryo, hyfrecatio, curette/cautery, excision
Tx of felon
Surgical drainage (make incision over point of maximal tenderness)
Abx, soaks, elevation
After incision leave open to heal by secondary intention
If deep, or does not respond quickly to tx, refer ASAP to hand surgeon
how do you tx a subungual hematoma?
Release blood w electrocautery through nail (or drill) > immediate relief
Apply ointment, dressing
Consider x rays to rule out tuft fracture
Common, fast and easy to tx with low risk of complications
What is an anal fistula?
Abnormal tube from rectum to external perianal or perineal area. Usually result of an abscess or inflammatory process
What is a pilonidal cyst? How do you tx it?
Vestigial cyst from embryonic development lined with endothelial tissue
In the sacrococcygeal nerve, can become inflamed, infected
Initial tx if infected is I&D; when infxn resolved can be surgically excised
Melanoma RF, most common type, tumor markers
RF: women, fhx, fair skin, AK, outdoor work, sun burns
Most common = superficial spreading
Most aggressive = nodular
Most common in elderly = Lentigo
Aggressive and most common in dark skin = Acral
Tx for human bites
Hand bites are HIGH RISK; refer to surgeon for IV antibiotics, observation. May need surgery.
NEVER suture closed
Tx for dog bites
Thorough cleansing, debridement if necessary
Usu leave open
Consider prophylactic antibiotics (always in cats, dogs with high risk infxn)
Consider tetanus, rabies prophylaxis
Refer if systemic sx of infxn, or if bite penetrates joint/lacerates a nerve or tendon
abx for dog bites should cover
Pasteurella multicida, strep, staph a, anaerobes
Amoxicillin - clav
Cephalosporin or doxy for penicillin allergies
Tx for foreign bodies
Only remove straightforward ones
Puncture wounds should be left open
ALWAYS REFER:
FB that may have penetrated the chest, abdominal cavity, eye, skull, or deep tissues of neck
Gunshot wounds
Vascular, tendon, nerve injury
Laceration classifying
Superficial vs deep (nerve, tendon, vasculature, bone)
Simple (no significant loss of tissue/contamination) vs complex
Clean vs dirty/contaminated
Steps of laceration repair
Anesthetize
Irrigation with NS (35 cc syringe)
Prep around wound with betadine or chlorhexidine
Consider debridement, reinspect wound, decide on type/size of suture
Dress wound, tetanus prophylaxis, abx
