Minor Surgery Part 2 Flashcards
For a patient with an allergy to the ester group, or PABA, use a ______________.
preservative-free amide
What is the most useful anesthesia in minor surgery?
Lidocaine (Xylocaine)
What is the maximum recommended dose for Lidocaine (Xylocaine) in adults?
4.5mg/kg
Not to exceed a ceiling of 300mg or 30 ccs of 1%
What is the maximum recommended dose for Lidocaine (Xylocaine) in kiddos (over 3 y/o)?
3.3-4.5 mg/kg
Not to exceed a total of 75-100 mg.
What is the dose interval for Lidocaine (Xylocaine)?
90min to 2 hour
What is the onset for Lidocaine (Xylocaine)?
Rapid onset (4-10 minutes)
Bupivacaine (Marcaine):
Duration?
Onset?
Longer duration (3-4 hours) Slower onset (8-12 min.)
Which LA can mix well with lidocaine and is good for digital blocks?
Bupivacaine (Marcaine)
What is the max dose for Bupivacaine (Marcaine)?
Maximum dose 4 mg/kg of 0.25%.
Which LA is similar to Lidocaine, but lasts longer (2-2.5 hours) and causes less drowsiness.
Mepivacaine (Carbocaine)
What is the maximum dose for Mepivacaine (Carbocaine)
Maximum dose 5 mg/kg of 1%
Which LA has a slower onset than Lidocaine, but similar duration. Good alternative to Lidocaine for those with allergies to amides.
Procaine (Novocaine)
Diphenhydramine (Benadryl): Inject 1% solution in same fashion as Lidocaine; may use with or without Epinephrine.
What is the onset?
What is the duration?
Onset ~ 5 minutes.
Duration ~ 30 minutes.
If not numb within 10 minutes use alternative method.
Which areas are contraindicated for use of epinephrine?
Areas supplied by end-arteries
digits, ears, nose, penis
What is the progression of 3 negative side effects of using epinephrine?
Vasoconstriction –> ischemia —> necrosis
Epinephrine is contraindicated in patients taking which 2 types of medications or who have which 2 conditions?
MAOIs and TCAs
Thyrotoxicosis and severe CV dz
What is an important prophylactic consideration for puncture wounds?
Tetanus
T/F: Puncture wounds should be debrided, sutured, and dressed with sterile dressing
FALSE! Puncture wounds should be LEFT OPEN!
What is the term for a segment of skin +/- subcutaneous tissue, cut or torn from its bed; may be partial (with a “flap” or pedicle still attached) or complete?
Avulsion
Which type of laceration has no significant loss of tissue or contamination with debris
Simple
Which type of laceration has tissue loss or damage, contains foreign matter: avulsions, deep abrasions, crush injuries
Complex
Which type of closure requires immediate suturing of the wound; for clean or minimally contaminated wounds less than 6-12 hours old; may be older (12-24 hours) if very clean, or in areas with good blood supply (face/neck).
Primary Closure
Which type of closure is for visibly contaminated wounds, or those seen after 12-24 hours. Irrigate well, debride, and pack with moist, sterile dressing. If wound appears clean (no pus, necrosis, signs of infection) after 3-4 days.
Delayed Primary Closure
Which type of closure is for grossly contaminated or already infected wounds, or primarily closed wounds, which have become infected (need to reopen). Healing is by wound contraction, granulation, epithelialization; usually causes scarring.
Open Treatment (Healing by Secondary Intention)
What are the ABCDEs of skin lesions?
A = Asymmetry B = Border irregular/indistinct C = Color variability (especially mixture of shades of brown and black, or 3 colors) D = Diameter (> 6-8 mm) E = Dynamic (any change in appearance or symptom: rapid growth, inflammation, bleeding, itching)
What are the 2 tissue destruction methods?
- Cryotherapy
2. Electrosurgery (electrocautery or hyfrecation)
What are 4 tissue preserving methods?
- Elliptical excision or biopsy
- Incisional biopsy
- Shave biopsy
- Punch biopsy
In order for a cryogen to be effective, it must have a boiling point of _____° C or lower.
-50° C
What are 4 types of cryogens? And what temp are they effective?
- Histofreeze™ (-50° C)
- CO2 Slush or Snow (-78.5° C)
- Nitrous oxide ( -89.5° C)
- Liquid nitrogen (-196° C)
What are 5 contraindications with use of cryogens?
Malignancies (melanoma), recurrent BCC, Raynauds, compromised circulation, sensitive or dark skin
Which cryotherapy is in an aerosol can with a 3 year shelf life, inhalation causes CNS depression and chronic exposure is hepatoxic?
HistoFreeze
Which cryotherapy is simple, cheap, not very effective, and not really used much anymore?
Dry-ice
Which cryotherapy is expensive, but can be stored indefinitely. Prolonged exposure may cause infertility or abortion?
Nitrous oxide
What is the most common cryotherapy? It can last weeks to months in a ________ bottle and is the most effective w/rapid and deep freezing.
Liquid nitrogen; Dewar bottle
What is the method for freezing a lesion?
Freeze —> thaw —> refreeze w/ freezing zone around lesion for 10-30 seconds
Blisters from cryotherapy form w/in ____ hours, scabs w/in _____ week(s), heals w/in ____ weeks.
2-3 hours
1 week
2-3 weeks
T/F: Liquid nitrogen can kill organisms, so it can be used straight from the Dewer bottle
FALSE! Liquid nitrogen should NEVER be used straight from the Dewer bottle
T/F: Cryotherapy may cause depigmentation
True
What are 3 contraindications with use of electrosurgery?
- Flammable EtOH
- Metal implants
- Jewelry
Which type of electrosurgery is indirect electrical current, very precise, no blood loss?
Electrocautery
Which type of electrosurgery is direct, high frequency current flowing through tissue to generate heat? It is quick and effective w/ minimal blood loss and great precision.
Hyfrecation
With hyfrecation, which requires a pad to complete the circuit and which does not?
Bipolar:
Unipolar:
Bipolar: requires pad to complete the circuit
Unipolar: No second electrode needed
What are 8 contraindications for minor surgery?
- Location (eyes, nose, groin, axilla, post. neck)
- Large size or blood supply
- Depth
- Young children
- Anticoagulant use or bleeding d/o
- Pulsating lesions
- Keloid former
- Systemic INFXN (depleted immune system)
Which type of wound should be referred out after it is secured, especially if there is any nerve tendon, joint, eye, or chest/abdomen involvement?
Puncture
With a puncture wound, which type of booster should be considered?
Tetanus
Don’t suture wounds older than __-__ hours or __ hours on the face?
8-12 hours; 24 hours
Which topical anesthetic is poorly absorbed and needs at least 10%?
Benzocaine
Which topical anesthetic is for ophthalmologist use, <1min onset, 15 min duration?
Proparacaine
Which topical anesthetic is for ENT procedures, <1min onset, 1-hour duration?
Cocaine
TAC is a combination of which 3 elements and is cheap and works QUICKLY?
- Tetracaine
- Epinephrine
- Cocaine
What is the technique of using a needle electrode placed in the lesion, the current passed through the tissue generates heat and coagulates the blood and cells?
Desiccation
What is the technique of using a larger electrode held just above the skin surface (no contact); a stream of sparks is drawn from the electrode to the point of treatment; the tissues are charred and destroyed? (Used after cutting/curettage.)
Fulguration
Which techniques has a bipolar electrode (like forceps) placed on the surface to be treated and the current flows between the two poles, generating heat and destroying the tissues (i.e. vessels) between the electrodes?
Coagulation
If the lesion is EPIDERMAL use which type of biopsy?
Shave
If the lesion is INTRADERMAL which type of biopsy is used?
Excision
Incision
Punch
Which type of biopsy is the complete removal of a lesion for histological diagnosis? The indications for this method are when the entire lesion can be removed. It is both diagnostic and curative.
Excisional biopsy
Make an elliptical excision in an elliptical shape with a ratio of :, the corners at __ degree angles with a #___ blade
3:1
30 degree
#15
Which type of biopsy is a narrow elliptic specimen taken from within a larger lesion?
Incisional Biopsy
What are 3 disadvantage of doing an incisional biopsy?
- May miss malignant area
- Bleeding
- Scarring
Which type of biopsy removes the protruding portions of raised, papular, superficial lesions with a scalpel and blade. Can be both diagnostic and therapeutic. If kept superficial, healing is rapid with minimal scarring.
Shave Biopsy
What is a major contraindication with doing a shave biopsy?
NEVER!!! Shave biopsy a malignant melanoma!
Which type of full thickness cylindrical biopsies are obtained by use of a tool called a trephine. Trephines range from 2 to 8 mm in size (4 mm most commonly used). Can completely remove small nevi, or use when multiple biopsies are needed for diagnosis of systemic skin disorders, rashes.
Punch Biopsy
T/F: A shave biopsy may obtain full thickness of dermis with minimal scarring
FALSE! A punch biopsy will do that, not a shave
Which epidermal lesion is:
- usually seen in the elderly (head, neck, dorsum of hands, forearms, trunk)
- flat-topped, verrucas, papule, “stuck-on” appearance, usually deeply pigmented, granular surface
- benign, but can resemble MM
Seborrheic Keratoses (seborrheic warts/basal cell papillomas)
Which epidermal lesion is:
small, fleshy, pedunculated lesions; often in neck/axillae
Skin Tags (acrochordons)/Papillomata
Which epidermal lesion is:
- Red, scaly, “sandpapery” patches of dysplastic epithelium, found on light-exposed skin; can become pigmented
- most common precancerous lesion of the skin (10-15% transform into SCC)
Actinic Keratoses (solar keratoses, senile keratoses)
Which epidermal lesion is:
-characterized by rapid growth, on light-exposed skin
round with rolled edges and central keratin plug; often inflamed
-usually spontaneously resolves ~ 6 months
-often difficult to distinguish from bcc in appearance; base may contain SCC
Keratoacanthoma
Which epidermal lesion is:
- benign epidermal neoplasms caused by HPV
- common; usually on hands, plantar surfaces, genitals (condyloma acuminata)
- avoid surgical removal, especially on face (will often resolve spontaneously)
Warts (verrucae)
Which epidermal lesion is:
-also caused by a virus; small, pearly hard papules w/umbilicated center
-usually eventually resolve spontaneously
if solitary, leave alone; try medical measures first
Molluscum Contagiosum
Which epidermal lesion is:
- the most common malignant skin tumor
- usually on the face or sun-exposed skin
- SLOW GROWING, small papule which spreads to a central ulcer w/”ROLLED BORDER”; edges are PEARLY w/fine telangiectasia
- locally invasive; rarely metastatic
- exposure to arsenic
Basal Cell Carcinoma
Which epidermal lesion is:
-FAST growing
-2nd most common skin cancer
usu. occurs on/in areas of sun exposure in fair-skinned people, but anywhere on skin/mucous membranes (even in dark-skinned people) if arsenic exposure, burn scars, radiation, previous trauma (also tobacco, ETOH)
-Actinic Keratoses are a precursor
-variable appearance; usually firm, irregular with a scaly, keratotic, bleeding, friable surface; indurated, crusty, may be ulcerated plaque (without rolled, translucent border)
these do have potential to METASTASIZE (especially those on mucous membranes, i.e., the lower lip, those secondary to arsenic, radiation, or burn scars)
Squamous Cell Carcinoma
Which dermal lesion is:
- very common; benign dermal lumps of fibrous tissue and blood vessels
- secondary to trauma
- more common in women; often on lower extremities, occasionally pigmented
- feel like “lentils” in the skin
Dermatofibroma (fibrous histiocytoma)
Which dermal lesion is:
- common, benign, inflammatory masses of blood vessels and fibroblasts
- erupt rapidly, usually secondary to trauma or infection (lips, tongue, palms)
- polypoid appearance w/”collar” around base; bright red, bleed easily
- can be confused with SCC, and MM, especially “amelanotic”
Pyogenic Granuloma
Which melanocytic lesion is:
- usually acquired; all grow and change, especially through puberty; most eventually disappear; therefore, growth alone (especially in the young) is not a sinister sign
- if any of the ABCD’s are present, refer immediately to a specialist for histological examination
- benign ones may be removed for cosmetic purposes
Nevi (junctional, compound, intradermal)
Which melanocytic lesion is:
-The most dangerous of all the malignant skin tumors
-5% of all skin cancers, but 75% of all skin cancer deaths; incidence rising prognosis is poor; quick and accurate dx is essential
-greatest risk factors: PHx, FHx, fair skin, many nevi, large nevi, dysplastic nevi
other risk factors: Hx of sunburns (especially early in life), evidence of sun damage, immunosuppression
Malignant Melanoma
What is the term for:
hyperplasia of spinosum layer, assoc. w/ hyperlipidemia, Cushing’s, and DM
Acanthosis Nigricans
What is the term for:
chronic scratching causing skin growth (scratch-itch cycle)?
Lichenification
What is the term for:
a slow growing, moveable capsule filled w/ keratin, sebum
Epidermal Inclusion Cyst (Sebaceous)
What is the term for:
moveable benign tumor of encapsulated fat tissue arising from the subcutaneous fascia
Lipoma
What is the term for:
Sebaceous cyst on the head
Pilar cyst (Wen)
What is the term for:
dandruff, cradle-cap
Seborrheic dermatitis
T/F: While hemangiomas do have a blood supply, they can be easily cut into
FALSE!! DO NOT cut into a hemangioma (Esp. Cavernous hemangioma)
What is the term for:
an infection that results in a collection of purulent material in a circumscribed and closed cavity
Abscess
Which number scalpel should be used in an I&D?
11
With I&D, what should the wound be loosely packed with?
Iodoform or plain gauze - leaving a protruding tail
What is the term for:
“Boils”, deep INFXN of hair follicles by Staph Aur.
Furunculosis
What is the term for:
Deep INFXN of a group of adjacent hair follicles
Carbuncle
What is the term for:
A rare disorder; chronic relapsing sepsis in apocrine glands of axillae, groin, with recurrent abscesses and sinus tracts
Hidradinitis Suppuritiva
What is the term for:
A vestigial cyst from embryonic development lined with endothelial tissue; in the sacrococcygeal area; can become inflamed, infected. Initial treatment if infected is I&D; when infection resolved can be surgically excised
Pilonidal Cyst
What is the term for:
This is an infection of the folds around the nail, usually bacterial (Staph aureus), occasionally viral (HSV), or fungal. It usually originates from a hangnail, sliver, or other minor injury. The area around the nail is red, swollen, and very painful secondary to tissue tension.
Paronychia
What is the term for:
An abscess formation, usually due to staph., in the distal pulp of the finger involving multiple septae and compartments; can cause rapid and significant destruction (necrosis) and osteomyelitis. PAD of the finger is swollen, red, extremely painful.
Felon
What is the term for:
Infection of the flexor tendon sheath, usually started by a small puncture wound, bite or felon. Can be very dangerous; can lead to loss of function of the hand; may require surgical drainage.
Purulent Tenosynovitis
What are 4 cardinal signs (Kanavel’s signs) are diagnostic for Purulent Tenosynovitis:
- Slight flexion of the finger
- Fusiform swelling of the finger
- Pain on passive or active extension of the finger
- Tenderness along the tendon sheath into the palm
What is the term for:
Slow growing cyst; exact etiology unknown, but develops as a result of degeneration of the synovium of a joint capsule, or a tendon sheath, possibly secondary to trauma. Most common location is dorsal wrist, followed by volar wrist, then volar base of finger.
Ganglion Cyst
What is the term for:
A fungal infection of the nails that is very resistant to topical treatment, and tends to recur even after treatment with the most powerful, hepatotoxic oral antifungals. The causative agents are usually Trichophyton mentagrophytes and Trichophyton rubrum (and occasionally Candida albicans). It is characterized clinically by lusterless, brittle, thickened nails with distal splitting or crumbling.
Onychomycosis, or Tinea unguium
What is the term for:
A linear ulcer in the margin of the anus
Fissures
What is the term for:
An abnormal tube like passageway from the rectum to the external perianal or perineal area. Usually a result of an abscess or inflammatory process.
Fistulas
What is the term for:
A group of thrombosed, distended VV. that cause frank rectal bleeding, can be painful, and can prolapse.
Hemorrhoids
What is the term for:
A plugging of hair follicles by keratin debris.
What are the 2 types?
Non-inflamed comedones - Acne vulgaris
- Open = ‘blackhead’
- Closed = ‘whitehead’
What is the term for:
Increased sebum production where bacterial lipase produces irritating fatty acids - causing an inflammatory RXN
Inflammatory type - Acne vulgaris
What is the term for:
Primary pigmentation disorder characterized by hypo-pigmentation and depigmentation, autoimmune destruction of melanocytes (localized to extensive areas of skin depigmentation)
Vitiligo
What is the term for:
A common pigmentation disorder that causes brown or gray patches to appear on the skin, primarily on the face.
Melasma
What is the term for:
A spindle-cell tumor derived from endothelial cell. Has raised, round/oval papule or plaques, pink/purplish/red on legs
Kaposi’s Sarcoma
What is the term for:
“Liver spots”, usu. benign from excess sun exposure
Solar lentigo
What is the term for:
Lesion of SubQ fat, reddish, painful, tender lumps most commonly located in the front of the legs below the knees. Caused by sarcoid, TB, Leprosy, histoplasmosis, coccidiomycosis, Crohn’s Dz.
Erythema nosodum
Which melanoma is the most aggressive?
Nodular
Which melanoma is the most common?
Superficial spreading
Which melanoma is the most common in dark skin? Is found on palms, soles, nails, and is aggressive.
Acral
What is the tumor marker for melanoma?
S-100
What is the term for:
A condition that is inflammation of the dermis and subQ fat caused by Group A Beta Hemolytic Strep or Staph Aur. Leads to necrotizing fasciitis or erysipelas (lymph involvement, Orange peel).
Cellulitis
What is the term for:
Red streaking along lymph nodes
Lymphangitis
What is the term for:
Strep INFXN or superficial lymphatics usu. d/t immunocompromised, trauma, ulceration, or skin injury
Erysipelas
What is the term for:
chronic venous insufficiency d/t DM or bed ridden
Stasis dermatitis
Which HPV types are assoc w/ genital transmission and are contagious?
6 and #11
Which HPV types are dysplastic?
16, #18, #31, and #33
Which condition is 6th disease, HHV 6/7, w/ maculo-papular rash w/ high fever?
Roseola infantum
What is the term for cranial-caudal macular-papular rash with CLAD and fever?
Rubella (German measles)
What is the condition that has cough, coryza, conjunctivitis, Koplick spots, and can lead to subacute sclerosing pancephalitis?
Measles
Which condition has vesicles on an erythematous base, has a prodrome w/ itch, possibly fever, it has 2 types and antibodies from the dorsal nerve root ganglion, arise in 4-6 weeks. It is sexually transmitted?
Type 1 is usu. found on which part of the body?
Type 2 is usu. found on which part of the body?
Herpes
Type 1: face
Type 2: genitals
Which supplement should be used with herpes? Which should be avoided?
Should use: Lysine
Avoid: Arginine
Which condition is a bacterial INFXN of the epidermis? It is the most common bacterial INFXN of the skin and 3rd most common skin disease among children. Caused by staph or Group A strep, it is a vesicle or pustule that ruptures and becomes a “honey-like crust” exudate over erosion that is surrounded by erythema.
Impetigo
Which condition presents along a dermatome and has neuritic pain w/ vesicular eruptions? Tx: Levadopa, UV light. Vaccine: Zostavax
Herpes Zoster
Which condition is a viral INFXN that is waxy, dome-shaped, pink lesion w/ small central crater and white papule. Commonly seen on eyelids, beard, neck, axillae, trunk, perineum, and buttocks. Tx: Salicylic acid
Molluscum contagiosum
Which condition has a microbe that produces azelaic acid that causes an inflammatory RXN, hypo-pigmentation d/t decreased in melanin synthesis and enlargement of melanosomes. Microbe has affinity for sebaceous glands as it requires fatty acids to survive. It is an asymptomatic, superficial, fungal INFXN w/ brown or white scaling macules. May itch and appear more dry and scaly. It is diagnosed by gold w/ Woods lamp, KOH+
Tinea versicolor
Which condition is an IgE (such as nickel. It is a skin condition in which blisters develop on the soles of your feet and/or the palms of your hands. The blisters are usually itchy and may be filled with fluid. Blisters normally last for about two to four weeks and may be related to seasonal allergies or stress.
Dyshidrotic eczema
Which condition is suspected human herpes virus 7? It initially begins as a single, large, oval, scaly, rose-colored plaque (Herald Patch). After 1-2 weeks, a papular rash develops parallel to the ribs in a ‘Christmas Tree’ distribution on the trunk.
Pityriasis Rosea
Which condition is most common on flexor surfaces and can be a eczema, IgE Rxn, Eosinophilia, Asthma, and hayfever? Can be tx’d w/ homeopathy (psorinum or sulphur).
Atopic Dermatitis
Which condition is an immunological Rxn of the skin? It has symmetrical vesicles and bullae w/ concentric rings (target lesions) - light and dark rings. It is an INFXN by mycoplasma pneumonia or herpes simplex virus (HSV).
Erythema multiforme
