obce minor surgery Flashcards
lidocaine (xylocaine) use
local anesthetic–most popular, w/without epinephrine
mepivacaine (carbocaine) use
local anesthetic–no epinephrine
procaine (novocaine) use
local anesthetic w/without epinephrine
bupivacaine (marcaine) use
local anesthetic-slow onset, long duration
TAC application and use
local anesthetic, pediatric patient local anesthetic, sponge with epinephrine, tetracaine, and cocaine.
ophthaine (proparcaine hydorchloride)
local anesthetic, for topical eye application
cetacaine (rostra spray)
topical local anesthetic, mucous membranes, 1-5 minute duration
ethyl chloride
topical local anesthetic- highly flammable, short duration (15-30sec)
4 main reactions to local anesthetic:
- cardiovascular rxn 2. excitatory CNS effects 3. allergic responses 4. vasovagal syncope secondary to apin and anxiety
epidermis
outermost layer of skin: contains no organs, nerve endings or vessels.
epidermis function
provides protection
epidermis layers
stratum germinativum (basal layer)-parent layer for new cells. Stratum corneum (most superficial) -keritinized or horny layer
dermis
lies immediately below the epidermis and is thicker, composed of connective tissue.
cells of the dermis
fibroblasts, macrophages, mast cells and lymphocytes
layers of dermis
- papillary dermis (richly vascular, more superficial) 2. reticular dermis (bulk of adnexal structures: hair follicles, sebaceous glands, sweat glands, nerve fibers, vascular plexi)
significance of dermis in minor surgery
key layer for achieving proper wound healing: anchoring site for superficial and deep sutures, must cleanse and debride properly and approximate edges.
superficial fascia
deep to dermis, layer of loose CT with fat
superficial fascia primary function
insulates against heat loss
superficial fascial layer injury
potential for creating dead space–hematoma, devitalized fat can lead to bacterial growth
deep fascia
dense, thin, discrete fibrous tissue layer, which encloses muscle groups. Functions to support and protect ST structures
Wound healing phases (1)
0-10 min: Immediate response to injury (vessels constrict, platelets aggregate, clotting is activated.
would healing phases (2)
inflammatory phase (chemotactic factors are released and attract granulocytes to wound area). Peak # of cells 12-24 hours
wound healing (3)
24 hours: epithelialization (epithelial cells of the stratum germinativum or basal layer undergo morphologic and functional changes
wound healing (4)
neovascularization: day 3-21. new vessels form
wound healing (5)
collagen synthesis. new collagen laid down (collagen fibrils formed by 2nd day)
wound healing (6)
wound contraction: scar that forms contracts centripetally
primary union
healing by first intention. Clean wounds with min tissue loss. Wounds can be closed by suture or tape within 6 hours without complications
secondary union
significant tissue loss: avulsions, infarctions, ulcerations, abscesses. Prone to significant wound contraction.
tertiary union (delayed closure)
wound that can be closed after 3-4 days of observations
what technical factors affect wound healing?
inadequate wound tension, excessive suture tension, reactive suture material, local anesthetics
what anatomical factors affect wound healing?
static skin tension, dynamic skin tension, pigmented skin, oily skin, body region
which conditions and diseased affect wound healing?
advanced age, severe alcoholism, acute uremia, diabetes, ehlers danlos, hypoxia, severe anemia, peripheral vascular disease, malnutrition
which drugs affect wound healing?
corticosteroids, NSAIDS, penicillamine, colchicine, anticoagulants, antineoplastic agents, positive effects of vit A, C, and zinc sulfate
superficial wounds
skin, subcutaneous tissue, fat, and or muscle
deep wounds
involve structures excluded in superficial wounds. Not in DC scope of practice
simple wounds
interrupted tissue with no sign loss or implantation of debris
complex wounds
loss or damage to tissue or contain foreign matter
clean wounds
little or no bacterial contamination
dirty wound
wounds older than 5 hours or with other reason to suspect contamination, also those contaminated by instrument of injury, and when there is impairment of local circulation.
signs of infection
redness, warmth, and swelling extending beyond the immediate confines of the wound. palpable induration of greater than .5 cm. Purulent discharge, regional lymphangitis and wound dehiscence (splitting).
of organisms present in infection
100,000 organisms per gram of tissue
MC organisms in infection
staph aureus
factors that increase wound infection
old wounds (>5 hrs), crushing mechanism, soil or foreign material, lower extremity wounds.
technical factors that increase wound infection
detergent scrub solutions, anesthetics with epinephrine, poor suturing technique, excessive suture tension, reactive suture material tincture of benzoin
patient conditions that increase wound infection
advanced age, diabetes, uremia, liver disease, malnutrition, corticosteroid therapy
loss of 20% body weight increases risk of infection how much?
3x
when are prophylactics necessary to decrease risk of infection?
wounds greater than 6 hours, lower extremity wounds, crushing mechanism wounds, human and cat bites, severely contaminated wounds and complicated hand wounds.
age group most susceptible to tetanus
over 50
very tetanus prone wounds
high level of bacterial contamination, over 24 hours old, containing devitalized tissue which cannot be debrided.
moderately tetanus prone wounds
moderate bacterial exposure, over 6 hours old, stallate or crush wounds deeper than 1cm, wounds extending into muscle.
not tetanus prone wounds
clean wounds, less than 24 hours old, no devitalized tissue.
fully immunized against tetanus
adults: min 3 doses of tetanus toxoid, first and second given 3 months apart, third in 6 months.
children: between ages 6-7, four doses.
boosters every 10 years
tetanus shots for those never immunized
first dose with wound repair, second in 4-8 weeks, third 6 months after 2nd.
bite
amount of tissue taken when placing suture needle
throw
each not of suture consists of a series of throws
superficial suture
sutures placed on surface of skin for final closure-made of non-absorbable material
deep suture
usually absorbable material-placed in superficial fascia (subcutaneous tissue) or dermis.
continuous sutures
wound closure involving many bites along length of wound w/out individual knots.
debridement
cleaning away of devitalized tissue or contaminants
devitalized tissue appearance
shredded blue, or blackish
hemostasis
must be obtained before wound closure to avoid hematoma.
how to achieve hemostasis
4x4 gauze pad with pressure, or direct clamping (last resort)
deep layer closure
all layers of skin must be brought into and held in proximity.
accurate skin apposition
created with an everted suture-achieved with right angle tissue bites.
wide suture bites require fewer or greater number of sutures
fewer
what is undermining
method to reduce tension, involves releasing dermis and superficial fascia from deeper attachments.
where is undermining used
scalp, forehead, and lower leg (particularly over the tibia)
tools for undermining
metzenbaum scissors, or iris scissors
simple interrupted suture
most common for clean wounds: sutures tied with individual knots
vertical mattress suture for which wounds
edges cannot approximate with simple interrupted suture: thin skin, flexural creases, high stress areas.
horizontal sutures
suture slightly more everted than vertical mattress
apical suture
used to close v-shaped wounds by drawing tip into place
intradermal subcuticular “pull-out” sutures
used to avoid prominent suture marks
thread for intradermal subcuticular sutures
nylon or fine monofilament
polyglycolic acid absorbable or non? braided or non? synthetic or non.
absorbable, braided, synthetic polymer
polyglycolic acid knot security
excellent ++++
polyglycolic acid reactivity
less reactive
polyglycan-910 (PG910/vicryl): absorbable or non, synthetic or non
absorbable, synthetic
polyglycan-910 (PG910/vicryl) knot security
good +++, not as good as polyglycoic acid
gut: absorbable or non
absorbable (ew)
gut: tensile strength
less than synthetic absorbables
gut: tissue reaction
reactive
monofilament nylon (ethilon, dermalon): absorbable/non?
non-absorbable
monofilament nylon (ethilon, dermalon): knot security
poor ++
polypropylene (prolene) absorbable or non?
non-absorbable
polypropylene (prolene) strength
strongest
polypropylene (prolene) knot security
poor +
polypropylene (prolene) braided/unbraided?
unbraided
braided non-absorbable sutures (4)
- silk-knot security ++++
- cotton
- braided nylon (nurulon)-knot security +++
- multifilament dacron (mersilene)-knot security ++++
braided non-absorbable sutures knot security
excellent
least reactive non-absorbable suture material
polypropylene (prolene)
most reactive non-absorbable suture material
silk
most reactive absorbable suture material
gut
least reactive absorbable suture material
polyglycolic acid (dexon) or polyglycan-910
curved needle basic types (2)
tapered and cutting
which is a smaller needle and material 6-0 or 1-0?
6-0
benefits of wound taping
easy to apply non-invasive no anesthesia required no suture scars better infection resistance
disadvantages of wound taping
not well suited for tissue with considerable tension, irregular shapes or concave surfaces.
not great for oily or moist skin
four types of occlusive wound dressings
- Films
- foams
- hydrocolloids
4 hydrogels
duoderm, comfeel, and ulcer dressing
hydrocolloids (occlusive wound dressing)
Op-site, tegaderm, bioclusive, uniflex, oproflex, ensure-it, thin film wound dressing and blister film
films (occlusive wound dressing)
synthaderm and epilock
foams (occlusive wound dressing)
vigilon
hydrogel (occlusive wound dressing)
which type of occlusive dressing gets smelly and drains fluid
hydrocolloids
cryosurgery
liquid nitrogen for superficial skin lesions
electrocautery
small hand-held cordless disposable cautery tool for cutting and coagulation of most skin lesions. Local anesthesia is necessary. some degree of scarring.
electrocautery disadvantage
smell of burning, scarring
hyfrecator (fulguration)
ideal for all superficial skin lesions-keratoses, angiomas, warts molluscums and papillomas. ideal for vascular lesions, hemostasis and obliteration.
Electrodes are not self sterilizing.
hyfrecator (fulguration) disadvantages
smell of burning, difficulty obtaining samples for histology
radio surgery
combined cutting and coagulation. minimal scarring.
radio surgery disadvantages
pronounced smell of burning
laser
converts electrical energy to into light energy. Great for a variety of skin conditions–tattoos, blemishes, tumors, birthmarks, facial aging.
laser contraindicaitons
cost and additional training
minor surgery treatments for spider veins
cautery, hyfrector, radio-surgery, laser
minor surgery treatments for viral warts
cyrosurgery, cautery, hyfrecator, radio-surgery, laser (rarely scalpel)
minor surgery treatments for ingrown toenails
cryosurgery (sometimes), hyfrecator (sometimes), radio-surgery, scalpel, laser
minor surgery treatments for keratosis
cryosurgery, cautery, hyfrector, radio-surgery, scalpel, laser
minor surgery treatments for basal cell carcinoma
cryosurgery, cautery, hyfrector, radio-surgery, scalpel, laser
furuncles and carbuncles
local staph infections–begin as infection of hair follicle
furuncle vs carbuncle
furuncle (singular) carbuncle (multiple)
paronychia
staph infection of the nail
nail removal anesthesia
nerve block-best option for complete avulsion.
field block
can epinephrine be used for nail removal
no
blade used for nail avulsion
flat-spatulated
matricectum
Matricectomy: the process of surgically or chemically destroying all or part of the base nail portion called the nail matrix. Complete destruction of the nail matrix results in permanent loss of that portion of the nail.
fish hook removal
anesthetize, push hook through, cut off tip and back hook out.
what percent of bites are from dogs/ cats/other animals
90/5/5
what bacteria is common to animal bites?
pasturella multocida (gram negative)
what should be treated as if rabies were present?
all animal bites
what type of wounds are animal bites?
dirty
where do most human bites occur
over the metacarpophalangeal joint on dorsum of hand (clenched fist)
bacteria most associated with human bites
eikenella corrodens
contraindications for snake bite treatment
cryotherapy, incision and suction, tourniquets/constrictive bands
what is frostbite
a form of peripheral vascular disease due to exposure to cold
frostbite treatment
internal and external rewarming
external with dry warmth
internal with warm liquid
treatment of vesicles or blebs from frostbite
transfer to hopsital or ED
burns of what extent are a medical emergency?
adults 15%
children 10%
first degree burn
epidermis only (sunburn)
second degree burn
most frequent burn, capillary wall destruction and edema and bleb formation
third degree burn
destructive tissue loss with subsequent scarring. referral to ED
rectum anatomy
begins at S3 level, descends along sacrum and coccyx and ends at upper pelvic diaphragm, 12-15cm long
anal canal anatomy
begins at anorectal junction, 3-4cm long, terminates at anal verge.
musculature and innervation of anorectal region
inner tube (visceral smooth muscle-autonomic control) outer tube (skeletal muscle-somatic control)
dentate line
midpoint of anal canal-undulating demarcation, 2cm from anal verge.
columns of morgagni
“pleated” longitudinal fold above the dentate line
crypts of morgagni
at the base of the columns of morgagni (can have obstruction and abscess formation
internal sphincter innervation
involuntary-sympathetics (motor) and parasympathetics (inhibitory)
bright red blood that drips into toilet and is free from stool
associated with bleeding internal hemorrhoids
blood on tissues
associated with anal fissures or abrasion of anal canal
melena
pathologic processes higher in GI tracts
blood and mucous in stool
low lying carcinoma or more commonly UC and crohns
skin tag
area of hypertrophied cutaneous tissue adjacent to anus
skin tag location (anus)
posterolateral quadrant
sin tag etiology
old external hemorrhoids anal fissure or fistula crohns disease condyloma acuminata anal neoplasia pruritus ani previous anorectal surgery
symptomatic skin tag treatment
ointments, hot sitz baths, removal
skin tag removal options
cryosurgery, laser or electrosurgery
pruritus ani
perianal itching
hemorrhoids
“sliding down” of the thick, vascular cushions within the anal lining.
hemorrhoid locations
left lateral, right lateral and posterolateral
percent of population over 50 affected by hemorrhoids
50-70%
external hemorrhoids
dilated venules of the inferior hemorrhoidal plexus below the dentate line.
internal hemorrhoids
symptomatic, swollen submucosal vascular tissue above the dentate line.
first degree hemorrhoid
no protrusion or bulge into lumen of rectal canal
second degree hemorrhoid
protrude at stool and reduce spontaneously
third degree hemorrhoid
produce at stool and must be manually reduced
fourth degree hemorrhoid
protrude at stool and cannot be reduced
mixed hemorrhoids
elements of internal and external hemorrhoids present
strangulated hemorrhoids
prolapsed hemorrhoids, due to spasm of sphincter, lose blood supply and will become gangrenous
definitive examination of hemorrhoids
anoscopy
proctosigmoidscopy
to visualize rectum and lower colon and exclude carcinoma and IBD
first degree hemorrhoid tx
diet change, stool softeners, suppositories and sitz baths
rubber band ligature
for first degree internal hemorrhoids not relieved by diet
sclerotherapy
injection of solution (5% phenol in vegetable oil) for hemorrhoids not relieved by diet
manual dilation of anus
to overcome obstruction due to constricting bands
cryotherapy for hemorrhoids problems
profuse foul smell for 2 weeks after until necrosed tissue sloughs off
keesay technique
non-surgical galvanic
historic hemorrhoid tx for chiros
uses 12-14 mA negative galvanic current across hemorrhoid and is repeated in 10-20 treatments
fissure in ano
painful linear ulcer in anal canal from just below dentat line to anal level
fissure in ano sx
pain after defecation
frank bleeding
constipation
dysuria
fissure in ano location
mid line posterior in men 99%
mid line posterior in women 90% with 10% anterior
lateral fissure indication of sever systemic disease
sentinel pile
swelling at lower end of fissure and swelling and fibrosis at proximal end in anal valves
when is surgical repair indicated for anal fissures
persistent pain or bleeding
exposure of internal sphincter muscle
induration of fissure edges
development of large sentinel pile
blue cyanotic hue of perianal skin
crohn’s disease
irradiation proctitis
iatrogenic condition of patients undergoing radiation therapy. most commonly related to cervical cancer.
tuberculosis affecting anorectum
caseating granuloma and acid fast bacilli in lesion
condylomata acuminata
most commonly seen disease of the anorectum. papilloma virus.
condylomata lata
secondary syphilis
neoplasms of the anorectal canal
squamous cell carcinoma (MC)
basal cell carcinoma
bowen’s disease
perianal paget’s disease
squamous cell carcinoma appearance
rolled everted edges and central ulceration
fistula
abnormal communication between any two epithelial surfaces
anal fistula
abnormal communication between the anal canal and perianal skin
anal fistula origin
crypts of morgagni (90%)
horseshoe fistula
upward tracking fistula that goes circumferentially around the anus
abscess vs fistula
abscess-acute manifestation
fistula-chronic situation
ddx for fistula
bartholin gland abscess sebaceous cyst TB osteomyelitis of the bony pelvis fissure urethroperineal fistula
most common benign condition of the large bowel
polyps
appearance of polyps
can be sessile, pedunculated or villous
which polyps are most likely malignant
villous
treatment for polyps
excisional biopsy
povidone-iodine surgical scrub
wound cleansing agents (wound periphery and hands)
povidone-iodine without detergent
wound cleansing agents (wound periphery)
chlorhexidine
hand cleanser
alternative wound cleanser
pluronic F-68
face cleaner
hexachloropene
alternative hand cleanser
teratogenic
ganglia
cystic swelling near joint capsules and tendon sheaths
ganglia tx
not covered by chiros
benign tumors
palpable and usually non-tender mobile encapsulations
malignant tumors
basal cell c
squamous cell c
melanoma
basal cell carcinoma
MC over 40 area exposed to light slow growing rarely penetrates the base membrane progress to have raised rolled edges and ulceration or necrotic center
squamous cell
sun exposed skin
appears as peels on skin or non-healing ulcer
vermillion border of upper lip, paranasal folds, ears, cheeks, axillary region
can arise from actinic keratosis
squamous cell tx
excisional biopsy
melanoma
most dangerous least frequent nevus shaped jet black occasionally has visible vascularization may ulcerate or bleed
dexon, dexon plus and dexon S
synthetic absorbable sutre
vicryl, coated vicryl
synthetic absorbable sutre
dacron, mersilen
braided silk or polyester
dermalon, ethilon, nurolon
nylon sutures