Minor Surgery - Part 1 Flashcards
What type of fluids from ALL patients should be considered infectious?
Blood and body, basically ALL fluids
The main components of Universal precautions include which 2 elements?
- Protective barriers
2. Sharps management
Accidents involving sharps (needle sticks, scalpels) are the greatest single cause of ______ infection in the workplace.
HIV
________ is the most frequently occurring work-related infectious disease in the U.S.
Hepatitis B
“________ ________” means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.
“Occupational Exposure”
“________” means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.
“Parenteral”
What is the definition of Personal Protective Equipment?
Anything used to protect a person from exposure
What are 5 items that qualify as PPE (Personal Protective Equipment)?
- Latex/Nitrile gloves
- Goggles
- CPR mouth barriers
- Aprons
- Respirators
What are 4 rules to remember for PPE (Personal Protective Equipment)?
- Always check gear for defects or tears before using
- If torn or defective - GET NEW
- Remove PPE before leaving contaminated area
- DO NOT REUSE!
Which instrument is…
- Tungsten carbide
- Blunt nose
- Ratchets
- Smooth
- Usually cross-hatched jaw (for better gripping)
Needle holder/driver
Which instrument is…
- Very fine
- Used for dissecting/trimming skin
- May be curved or straight
- Do NOT use to cut sutures or bandages
Iris scissors
Which instrument is…
- Used for handling tissue
- Does NOT crush skin/tissue
Toothed Adson
Which instrument is…
- Used for grasping sutures, foreign bodies, picking things up, sterilely
- NOT used for grasping skin/tissues
Toothless Adson
Which instrument is…
- Used for removing scalpel blades
- Holds tourniquets
- Clamps vessels
- Hold skin tags or toenails
- May be curved or straight
Hemostats (AKA: clamps, forceps, Kelly’s, mosquitos)
Which scalpel is usu. disposable and attaches to sterile, reusable handles?
3
Which scalpel is used for stabbing/incising the skin? Commonly used during an I&D procedure.
11
Which scalpel is a standard blade for excision, trimming, or dissecting tissue?
15
Which scalpel is similar to a #15 (standard blade for excision, trimming, or dissecting tissue) but is for larger, thick, tough skin (like the back and scalp)?
10
To insure the effectiveness of any sterilization or disinfecting process, instruments must first be …
thoroughly cleaned of all visible contamination (retained foreign material can protect microorganisms from sterilization).
Initially, after instrument use, clean with a plastic brush under COOL water, why?
Hot water can coagulate blood, and make it harder to clean.
Instruments should be carefully dried, and lubricated with which type of lubricant?
a water-soluble lubricant like instrument milk. Oils or grease should NEVER be used.
What type of solution causes major pitting of instruments if allowed to soak or dry on them?
Saline
What is the term for:
The destruction of all living microorganisms, including bacterial spores
Sterilization
What is the term for:
The reduction of a population of pathogenic microorganisms without achieving sterility (not all bacterial spores are destroyed)
Disinfection
What is the term for:
A germicidal, chemical substance used on inanimate objects to kill pathogenic microorganisms, but not necessarily all other.
Disinfectant
What is the term for:
A chemical agent applied to the body that kills or inhibits the growth of pathogenic microorganisms.
Antiseptic
Differentiate between sterilization and disinfection
Instruments can be sterilized, people CAN NOT!
T/F: Alcohol (70%)/Chlorhexadine (5%) can be used for “emergency disinfection”.
True; Two (2) minutes of immersion; but it does not sterilize
What is the liquid disinfectant of choice (the only disinfectant solution that has shown some degree of reliability)?
2% Glutaraldehyde
2% Glutaraldehyde disinfects after soaking for ____ minutes and sterilizes (destroys spores) after ____ hours.
10 minutes; 10 hours
T/F: 2% Glutaraldehyde has high tissue toxicity so it should not be used for rubber, plastic, heat sensitive equipment.
FALSE! 2% Glutaraldehyde has low tissue toxicity; can be used for rubber, plastic, heat sensitive equipment (Cidex, Sonicide).
Which method is simple, quick, and effective method of disinfecting instruments (100°C [212°F] for 5 minutes), but should not be used for sterilization unless better methods are not available (may not destroy certain spores, viruses).
Boiling
To sterilize with boiling, instruments should be boiled at least _______ minutes at sea level (longer at higher altitudes).
30 minutes
Hot Air Ovens (Dry Heat) will sterilize instruments at ___°C (320°F) for how long? Works for glassware and things that would be damaged by moisture. What items should not be sterilized by hot air ovens?
160°C (320°F) for one hour
Cannot use for rubber, plastic, cloth, paper.
What is the most efficient and reliable method of sterilizing? Works for most materials and is easy and quick. Can sterilize wrapped instrument packs.
Autoclave
What is the steam pressure for autoclave? ____ psi (121C) for ____ minutes will destroy all forms of life.
15 psi (121C) for 15 minutes will destroy all forms of life.
What indicates suture size? What does that mean? The more O’s the ______ the thread.
O; finer
The smaller the size suture, the _____ tensile strength it has.
Less
T/F: NB: 3/0, 3-0, 000 are all the same size suture
True
Natural sutures are made from ______ _______, and are eventually digested by _______ ______, which attack and break down the suture strand.
mammalian collagen; body enzymes
Synthetic absorbable sutures are polymers, which are _________.
Hydrolyzed (water gradually penetrates the suture filaments, causing breakdown of the polymer chain)
_________sutures are used for temporary approximation of wound edges, particularly subcutaneous tissues and mucous membranes, dentistry, obstetrics, deep skin wounds.
Absorbable
________ sutures are made of a single strand of material which means there is less resistance as they pass through tissue and are less likely to harbor microorganisms. These sutures tie easily, but knots may slip and may break easily.
Monofilament
______ sutures are several strands braided or twisted together. They are stronger, more pliable and flexible, and slip less easily, but may harbor organisms, which can lead to infection.
Multifilament
Which natural suture is rapidly absorbed and has some problems with tissue reaction, antigenicity; but good for tissues, which heal rapidly, need minimal support (mouth).
Plain catgut
What is the tensile strength half life of plain catgut?
7-10 days
Chromic catgut is treated with ______ _____ to delay absorption by body enzymes
chromium salts
What is the tensile strength half life of Chromic catgut?
2-3 weeks
Which has less tissue reaction, plain catgut or chromic catgut?
Chromic catgut
Synthetic polymers; absorption is by ________, therefore minimal tissue reaction; easy to tie, increased tensile strength
hydrolysis
Which synthetic polymer is braided and monofilament. Coated to allow smooth passage through the skin. Easy to tie.
What is the tensile strength half life?
- Polyglactic acid (Vicryl)
- Tensile strength half life is 4-7 weeks
Which synthetic polymer is monofilament; almost no tissue reaction.
- Polyglycolic acid (Dexon)
- Tensile strength half life is 2-3 weeks
Which synthetic polymer is amonofilament polyester polymer.
What is the tensile strength half life?
- Polydioxanone (PDS)
- Tensile strength 4-6 weeks
Which non-absorbable suture is braided, easy to tie, but has increased (high) risk of infection? Tensile strength approximately 1 year, therefore actually very slowly absorbing suture (vessel ligation, not used much for skin anymore).
Silk
Which non-absorbable suture is a polyamide polymer; monofilament? Low tissue reactivity, low risk of infection, high tensile strength, easy to handle but need extra knots to prevent slippage (skin, subcuticular tissues).
Nylon (Ethilon)
Which non-absorbable suture is monofilament? Similar to nylon (Ethilon). More supple, longer retention, slick; more expensive (skin, sub-Q tissues, heart valves, contaminated, INFX wounds).
Polypropylene (Prolene)
Which non-absorbable suture is permanent; minimal tissue reaction (abdominal and sternal wound closure, tendon repair).
Stainless steel
What other non-absorbable, natural sutures have a high tissue reactivity?
Polyester (Mersilene, Ethibond), Polybutester (Novafil)
What is an alternative/adjunctive closing item is especially useful in high tissue areas? What application method should be avoided? What should be applied with this?
- Steri-strips
- DONT ENCIRCLE DIGITS (can have a tourniquet effect)
- Apply w/ Benzoin
Which suture is better tolerated and has less risk of INFXN (Natural or synthetic)?
Synthetic
Which tissue adhesive is a sterile “Krazy Glue”? How many layers should be applied? How long does it take to set?
Cyanoacrylate tissue adhesive (Dermabond)
3 layers
50 seconds
How long does it take Dermabond to be as strong as sutures? How does the Dermabond come off and how long does that take?
- 2 1/2 minutes
- sloughs off of skin as wound heals within 5-10 days
Which areas of the body can Dermabond NOT be used?
Areas of excess motion or moisture (knees, elbows, hands/feet, inside mouth, groin areas)
What are the 3 basic components of stainless steel w/silicone coating needles?
- the attachment end (“swaged end”, i.e., the attachment of the suture to the needle)
- the body
- the point
Conventional Cutting needle is not used so much anymore. Where is it most commonly seen used?
cosmetic surgery
Which needle is the MOST COMMON for skin? Cuts through tough, difficult to penetrate tissue. Leaves good tissue bridge (skin, tendon sheath, oral mucosa).
Reverse Cutting needle
Which type of needle pierces and spreads tissue without cutting it. For easily penetrated tissue such as bowel, myocardium, fascia, muscle.
Tapered needles
Which type of needle can dissect friable tissue as opposed to cutting it. Used for friable tissues and in deep cavities for safety considerations (liver, kidney, spleen, cervix).
Blunt needle
Which part of the needle should be grasped with the needle holder? Which area should not be grabbed?
- Body (shaft)
- DO NOT grasp the swaged end
What is the rule of thumb for knots and sutures?
Use one more knot than gauge of suture
Which suture size should be used on the face/neck and when should it be removed?
5-0 to 6-0
Remove after 3-5 days
Which suture size should be used on the arm/hands and when should it be removed?
4-0 to 5-0
Remove after 7-10 days
Which suture size should be used on the trunk/legs/feet/scalp and when should it be removed?
3-0 to 4-0
Remove after 7-14 days
Which type of knot is the most secure and reliable; easiest to make knots “square”?
Two-handed tie
Which type of knot is the fastest, don’t have to put down needle holder? Good for deep spaces.
One-handed tie
Which type of knot is useful for conserving suture, working with short ends.
Instrument tie
What are 5 components of the sterile field?
- Drapes
- Gloves
- Syringes/needle/sutures
- Instruments
- Wound/skin prep
T/F: Hairy areas should be shaved during wound/skin prep to limit risk of INFXN
FALSE! DO NOT shave hairy areas
When disinfecting intact skin which 2 preparation agents can be used?
- 10% povidone-iodine (Betadine)
2. 4% chlorhexidine gluconate (Hibiclens)
T/F: Betadine, Hibiclens, and hydrogen peroxide are the best choices for use in open wounds
FALSE!!! DO NOT use these in any open wound! However, they can be used for intact tissue AROUND the open wound
Open wounds should be irrigated with ________. How should that be administered?
- Normal saline
- 35ml syringe with a 19 gauge needle
Hemostasis (coagulation):
Injury results in disruption of blood vessels, extravasation of blood constituents, initiation of the coagulation cascade, formation of a ______ _____.
fibrin clot
What are the 5 components of inflammation?
- Platelets
- Neutrophils
- Macrophages
- Re-epithelialization
- New keratinocytes
Platelets secretes ______. Clot formation triggers _______ ______
cytokines; complement cascade
Neutrophils arrive w/in ___-___ hours to destroy bacteria and lasts __-___ days (or longer if wound is significantly contaminated)
5-6 hours
3-4 days
_____ transition from inflammation to repair and phagocytize and remove fibrin clot.
Macrophages
Re-epithelialization begins w/in hours of injury as _____ cells begin to migrate over the gap. The gap is bridged in ___-___ hours in a repaired wound. In a wound left open epithelialization occurs at about __mm per day.
Basal cells
24-48 hours
1mm
New keratinocytes begin to proliferate ___-___days after injury at margins of wound.
1-2 days
Granulation or Proliferation begins __-__ days after injury; and lasts ~ __ weeks)
3-4 days
3 weeks
Fibroblasts migrate to the wound (attracted by cytokines from macrophages, platelets, other fibroblasts), produce a fibronectin matrix, then produce ______ and other components of new connective tissue (elastin, proteoglycans).
collagen
________ occurs by endothelial budding and anastomosis of capillaries across the defect; the new vessels bring oxygen and nutrients to the healing wound.
Angiogenesis
The newly formed capillaries surrounded by fibroblasts give the wound surface a characteristic appearance referred to as ______ ______.
granulation tissue
Remodeling and wound contraction happens from ___ weeks to ___-___ months
3 weeks to 6-18 months
What is the % strength by 3-4 weeks and what % by 1 year
30-40% by 3-4 weeks
80% by 1 year
Wound contraction is normal and occurs due to _________ and _______of _______.
myofibroblasts; orientation of collagen
What is abnormal formation of a tight scar due to excessive contraction which limits motion and causes deformity?
Contracture
What is the single most important cause of delayed wound healing?
Wound infection
If equilibrium between collagen production and lysis does not occur at ___-___weeks, the wound will expand and become elevated, wider and deeper than normal, forming an abnormal scar.
3 to 4 weeks
What is the most common type of abnormal scar: wide, red, elevated, but do not involve previously uninjured tissue?
Hypertrophic Scars
Which scar is similar in appearance to hypertrophic scars, but continue to enlarge beyond the original dimensions of the wound in psuedotumor fashion; genetic predisposition to ______ formation (more prevalent in dark-skinned people); exact etiology is unknown?
Keloid Scars; keloid
What is Vitamin C’s function in wound healing?
Promotes collagen formation and healing of connective tissue
What is Zinc’s function in wound healing?
DNA/RNA synthesis, collagen synthesis, and cross-linking as well as immune function
What is Vitamin B’s function in wound healing?
Collagen, cross-linking, DNA synthesis
What is Copper’s function in wound healing?
Collagen cross linking
What is Vitamin E’s function in wound healing?
Reduce scar formation, adhesions
What is Flavonoid’s function in wound healing?
Reduce scar formation
What type of wound healing is… “sutured wounds”, produced when the edges of a full-thickness wound are re-approximated
can be used in clean wounds with minimal tissue loss, less than 6-12 hours old, caused by shearing forces such as a knife
Primary/First Intention
What type of wound healing is…
Full thickness wounds which are allowed to heal “naturally”, or left “open”, not closed with sutures
Allowed to heal by granulation and eventual re-epithelialization, they contract significantly over time
Should be used in wounds with significant tissue loss, devitalization, or contamination/infection (avulsions, ulcerations, abscesses)
Secondary Intention
Sometimes wounds which were sutured, then become infected, need to be re-opened and left to heal by ____ ______
Secondary Intention
What type of wound healing is…
Wounds that are grossly contaminated but have not suffered significant tissue loss or devitalization (> 12 hours old, animal bites, large puncture wounds) may be treated with delayed primary closure
The wound must be cleaned, irrigated and debrided as much as possible during the initial encounter. Pack the wound with sterile fine-mesh gauze or gauze sponges soaked in normal saline. Cover the wound with a bulky absorbent dressing. Oral antibiotics should be considered after initial care and before delayed closure is performed.
Tertiary Intention
What is the disadvantage with using simple interrupted stitch?
Railroad track scarring and it may be difficult to evert the edges. It can also be time consuming.
The vertical mattress stitch is slightly more complicated than simple interrupted, but much better for ______ _____ ____ ; allows precise approximation of the wound with little tension, better for ________.
everting skin edges; cosmesis
Vertical mattress stitch is good for which wounds?
Wounds under tension, thick skin (palms, soles), or loose skin, which tend to invert
What are disadvantages with using the vertical mattress stitch?
Railroad track scarring and can be time consuming
Deep or buried stitch is good for…
decreasing tension and dead space in larger, deeper wounds (such as removal of lesions)
Knots for deep or buried stitches are “______”, so will be below skin margins.
inverted
Subcuticular/Intradermal Running Stitch is placed _____ ___ ____, so is not visible.
in the dermis; cosmetically nice, eliminates “tracks”.
Subcuticular/Intradermal Running Stitch works best in wounds where there is ______ tension, and in clean, linear wounds (i.e., surgical incisions as opposed to lacerations).
minimal
Continuous running stitch is rapid, non-cosmetic, ____ secure, and has a _____ risk of INFXN
Less; higher
What is the horizontal mattress stitch used for? Which area of the body are they best for?
High tension wounds and fragile tissues; palms or soles
What are 3 advantages to using the horizontal mattress stitch?
- Optimizes wound edge eversion
- Increased closure strength (distributes tension)
- Spreads tension along wound edge
For post-op care, how long should a wound be kept dry? How often should wounds be redressed?
24-48 hours
3-4 days
When does infection tend to set up? What is the most common offending bacteria?
4-10 days post-op
Staph Aureus
What are 4 reasons for dressing?
- Absorption of drainage
- Provides support
- Moisture for epithelialization
- Limits movement
From least invasive to to most what is the order of 5 dressings?
- Non-adherent
- Gauze
- Elastic
- Tape
- Occlusive
What is blood collection following surgery and may lead to INFXN or dehiscence? What is the time frame for this?
Hematoma
24-72hours
What is a wound rupture along an incision after sutured closed? When should the wound be re-sutured?
Dehiscence
Re-suture w/in 48-72 hours
What are 4 almost certain signs of wound infection?
- Purulent discharge
- Regional lymphangitis
- Dehiscence
- Fever
When does wound infection become evident?
4-10 days
Local anesthetics block _____ reuptake to prevent ________ and ___________ of pain stimuli.
Na+; depolarization and propagation
Because depolarization is prevented this is called a non-depolarized block.
What are 4 main pharmacological properties to consider when choosing a local anesthetic?
- Rate of onset
- Degree of action
- Duration of action
- Allergic potential
What are the 2 main classifications of anesthetics?
- Amides
2. Esters
Amides are metabolized in the _________ by microsomal enzymes.
Liver
therefore patients with decreased hepatic function are predisposed to adverse effects of amide anesthetics
Most of the time allergic reactions are due to the antibacterial additive ________, related to PABA, a highly allergenic compound.
methylparaben
What is the math of anesthetics?
10cc of 1% = ____mg
1cc of 1% = _____mg
10cc of 1% = 100mg
1cc of 1% = 10 mg
(Hint: what ever the cc, add a 0 to determine mg!)
Esters are metabolized in the _______ by ____________
plasma by pseudocholinesterase
therefore patients with genetically abnormal pseudocholinesterase are predisposed to adverse effects
A principle metabolite of esters is _____________, which is strongly associated with allergic reactions.
para-aminobenzoic acid PABA
What is the degree angle of injection for: IM, SubQ, and ID?
IM: 90 degrees
SubQ: 30-45 degrees
ID: 5-10 degrees
Epinephrine is added to cause vasoconstriction in order to do what 3 things?
- Decrease oozing
- Prolong the duration of the anesthetic effect (by limiting absorption and enhancing the local neural membrane uptake),
- Decrease risk of toxic reactions (by reducing circulating levels of LA)
What are 3 types of adverse RXNs of anesthetic?
- Toxic Rxn
- Allergic/hypersensitivity Rxn
- Autonomic Rxn
Which type of adverse reaction is inadvertent intravascular injection or dose (MC cause). It will be a CNS depressant that may cause HYPOtension first, then BRADYcardia or cardiac arrest?
Toxic Rxn
How is a toxic reaction treated?
O2
Which type of adverse reaction is similar to allergic presentation with TACHYcardia, sweating, dizziness, HYPERtension, and syncope?
Autonomic Rxn
How is an autonomic reaction treated?
Usually resolves w/in minutes and requires minimal intervention
What is the most common type of adverse reaction?
Autonomic Rxn
True allergic reactions/anaphylaxis are extremely rare with LAs (less than 1% of all adverse reactions).
When do Type I (IgE) reactions occur?
after a sensitizing dose
How is an allergic reaction treated? Mild and severe…
Mild cases: Benadryl
Severe cases: Epinepherine and O2
Which type of anesthetic has the most common allergic/hypersensitive reaction?
Esters (Procaine)
What are 5 side effects from use of Epinephrine?
- Anxiety
- Restlessness
- Tremors
- Palpitations
- Tachycardia
What is the dose ____-____concentrations w/ MAX of ________mg.
1:100,000-200,000;
less than 0.2mg
What is the antidote for epinephrine?
IV push of magnesium and vitamin B6 to increase COMT metabolism
