obce minor surgery Flashcards
1
Q
lidocaine (xylocaine) use
A
local anesthetic–most popular, w/without epinephrine
2
Q
mepivacaine (carbocaine) use
A
local anesthetic–no epinephrine
3
Q
procaine (novocaine) use
A
local anesthetic w/without epinephrine
4
Q
bupivacaine (marcaine) use
A
local anesthetic-slow onset, long duration
5
Q
TAC application and use
A
local anesthetic, pediatric patient local anesthetic, sponge with epinephrine, tetracaine, and cocaine.
6
Q
ophthaine (proparcaine hydorchloride)
A
local anesthetic, for topical eye application
7
Q
cetacaine (rostra spray)
A
topical local anesthetic, mucous membranes, 1-5 minute duration
8
Q
ethyl chloride
A
topical local anesthetic- highly flammable, short duration (15-30sec)
9
Q
4 main reactions to local anesthetic:
A
- cardiovascular rxn 2. excitatory CNS effects 3. allergic responses 4. vasovagal syncope secondary to apin and anxiety
10
Q
epidermis
A
outermost layer of skin: contains no organs, nerve endings or vessels.
11
Q
epidermis function
A
provides protection
12
Q
epidermis layers
A
stratum germinativum (basal layer)-parent layer for new cells. Stratum corneum (most superficial) -keritinized or horny layer
13
Q
dermis
A
lies immediately below the epidermis and is thicker, composed of connective tissue.
14
Q
cells of the dermis
A
fibroblasts, macrophages, mast cells and lymphocytes
15
Q
layers of dermis
A
- papillary dermis (richly vascular, more superficial) 2. reticular dermis (bulk of adnexal structures: hair follicles, sebaceous glands, sweat glands, nerve fibers, vascular plexi)
16
Q
significance of dermis in minor surgery
A
key layer for achieving proper wound healing: anchoring site for superficial and deep sutures, must cleanse and debride properly and approximate edges.
17
Q
superficial fascia
A
deep to dermis, layer of loose CT with fat
18
Q
superficial fascia primary function
A
insulates against heat loss
19
Q
superficial fascial layer injury
A
potential for creating dead space–hematoma, devitalized fat can lead to bacterial growth
20
Q
deep fascia
A
dense, thin, discrete fibrous tissue layer, which encloses muscle groups. Functions to support and protect ST structures
21
Q
Wound healing phases (1)
A
0-10 min: Immediate response to injury (vessels constrict, platelets aggregate, clotting is activated.
22
Q
would healing phases (2)
A
inflammatory phase (chemotactic factors are released and attract granulocytes to wound area). Peak # of cells 12-24 hours
23
Q
wound healing (3)
A
24 hours: epithelialization (epithelial cells of the stratum germinativum or basal layer undergo morphologic and functional changes
24
Q
wound healing (4)
A
neovascularization: day 3-21. new vessels form
25
wound healing (5)
collagen synthesis. new collagen laid down (collagen fibrils formed by 2nd day)
26
wound healing (6)
wound contraction: scar that forms contracts centripetally
27
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
28
secondary union
significant tissue loss: avulsions, infarctions, ulcerations, abscesses. Prone to significant wound contraction.
29
tertiary union (delayed closure)
wound that can be closed after 3-4 days of observations
30
what technical factors affect wound healing?
inadequate wound tension, excessive suture tension, reactive suture material, local anesthetics
31
what anatomical factors affect wound healing?
static skin tension, dynamic skin tension, pigmented skin, oily skin, body region
32
which conditions and diseased affect wound healing?
advanced age, severe alcoholism, acute uremia, diabetes, ehlers danlos, hypoxia, severe anemia, peripheral vascular disease, malnutrition
33
which drugs affect wound healing?
corticosteroids, NSAIDS, penicillamine, colchicine, anticoagulants, antineoplastic agents, positive effects of vit A, C, and zinc sulfate
34
superficial wounds
skin, subcutaneous tissue, fat, and or muscle
35
deep wounds
involve structures excluded in superficial wounds. Not in DC scope of practice
36
simple wounds
interrupted tissue with no sign loss or implantation of debris
37
complex wounds
loss or damage to tissue or contain foreign matter
38
clean wounds
little or no bacterial contamination
39
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.
40
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).
41
of organisms present in infection
100,000 organisms per gram of tissue
42
MC organisms in infection
staph aureus
43
factors that increase wound infection
old wounds (>5 hrs), crushing mechanism, soil or foreign material, lower extremity wounds.
44
technical factors that increase wound infection
detergent scrub solutions, anesthetics with epinephrine, poor suturing technique, excessive suture tension, reactive suture material tincture of benzoin
45
patient conditions that increase wound infection
advanced age, diabetes, uremia, liver disease, malnutrition, corticosteroid therapy
46
loss of 20% body weight increases risk of infection how much?
3x
47
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.
48
age group most susceptible to tetanus
over 50
49
very tetanus prone wounds
high level of bacterial contamination, over 24 hours old, containing devitalized tissue which cannot be debrided.
50
moderately tetanus prone wounds
moderate bacterial exposure, over 6 hours old, stallate or crush wounds deeper than 1cm, wounds extending into muscle.
51
not tetanus prone wounds
clean wounds, less than 24 hours old, no devitalized tissue.
52
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
53
tetanus shots for those never immunized
first dose with wound repair, second in 4-8 weeks, third 6 months after 2nd.
54
bite
amount of tissue taken when placing suture needle
55
throw
each not of suture consists of a series of throws
56
superficial suture
sutures placed on surface of skin for final closure-made of non-absorbable material
57
deep suture
usually absorbable material-placed in superficial fascia (subcutaneous tissue) or dermis.
58
continuous sutures
wound closure involving many bites along length of wound w/out individual knots.
59
debridement
cleaning away of devitalized tissue or contaminants
60
devitalized tissue appearance
shredded blue, or blackish
61
hemostasis
must be obtained before wound closure to avoid hematoma.
62
how to achieve hemostasis
4x4 gauze pad with pressure, or direct clamping (last resort)
63
deep layer closure
all layers of skin must be brought into and held in proximity.
64
accurate skin apposition
created with an everted suture-achieved with right angle tissue bites.
65
wide suture bites require fewer or greater number of sutures
fewer
66
what is undermining
method to reduce tension, involves releasing dermis and superficial fascia from deeper attachments.
67
where is undermining used
scalp, forehead, and lower leg (particularly over the tibia)
68
tools for undermining
metzenbaum scissors, or iris scissors
69
simple interrupted suture
most common for clean wounds: sutures tied with individual knots
70
vertical mattress suture for which wounds
edges cannot approximate with simple interrupted suture: thin skin, flexural creases, high stress areas.
71
horizontal sutures
suture slightly more everted than vertical mattress
72
apical suture
used to close v-shaped wounds by drawing tip into place
73
intradermal subcuticular "pull-out" sutures
used to avoid prominent suture marks
74
thread for intradermal subcuticular sutures
nylon or fine monofilament
75
polyglycolic acid absorbable or non? braided or non? synthetic or non.
absorbable, braided, synthetic polymer
76
polyglycolic acid knot security
excellent ++++
77
polyglycolic acid reactivity
less reactive
78
polyglycan-910 (PG910/vicryl): absorbable or non, synthetic or non
absorbable, synthetic
79
polyglycan-910 (PG910/vicryl) knot security
good +++, not as good as polyglycoic acid
80
gut: absorbable or non
absorbable (ew)
81
gut: tensile strength
less than synthetic absorbables
82
gut: tissue reaction
reactive
83
monofilament nylon (ethilon, dermalon): absorbable/non?
non-absorbable
84
monofilament nylon (ethilon, dermalon): knot security
poor ++
85
polypropylene (prolene) absorbable or non?
non-absorbable
86
polypropylene (prolene) strength
strongest
87
polypropylene (prolene) knot security
poor +
88
polypropylene (prolene) braided/unbraided?
unbraided
89
braided non-absorbable sutures (4)
1. silk-knot security ++++
2. cotton
3. braided nylon (nurulon)-knot security +++
4. multifilament dacron (mersilene)-knot security ++++
90
braided non-absorbable sutures knot security
excellent
91
least reactive non-absorbable suture material
polypropylene (prolene)
92
most reactive non-absorbable suture material
silk
93
most reactive absorbable suture material
gut
94
least reactive absorbable suture material
polyglycolic acid (dexon) or polyglycan-910
95
curved needle basic types (2)
tapered and cutting
96
which is a smaller needle and material 6-0 or 1-0?
6-0
97
benefits of wound taping
```
easy to apply
non-invasive
no anesthesia required
no suture scars
better infection resistance
```
98
disadvantages of wound taping
not well suited for tissue with considerable tension, irregular shapes or concave surfaces.
not great for oily or moist skin
99
four types of occlusive wound dressings
1. Films
2. foams
3. hydrocolloids
4 hydrogels
100
duoderm, comfeel, and ulcer dressing
hydrocolloids (occlusive wound dressing)
101
Op-site, tegaderm, bioclusive, uniflex, oproflex, ensure-it, thin film wound dressing and blister film
films (occlusive wound dressing)
102
synthaderm and epilock
foams (occlusive wound dressing)
103
vigilon
hydrogel (occlusive wound dressing)
104
which type of occlusive dressing gets smelly and drains fluid
hydrocolloids
105
cryosurgery
liquid nitrogen for superficial skin lesions
106
electrocautery
small hand-held cordless disposable cautery tool for cutting and coagulation of most skin lesions. Local anesthesia is necessary. some degree of scarring.
107
electrocautery disadvantage
smell of burning, scarring
108
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.
109
hyfrecator (fulguration) disadvantages
smell of burning, difficulty obtaining samples for histology
110
radio surgery
combined cutting and coagulation. minimal scarring.
111
radio surgery disadvantages
pronounced smell of burning
112
laser
converts electrical energy to into light energy. Great for a variety of skin conditions--tattoos, blemishes, tumors, birthmarks, facial aging.
113
laser contraindicaitons
cost and additional training
114
minor surgery treatments for spider veins
cautery, hyfrector, radio-surgery, laser
115
minor surgery treatments for viral warts
cyrosurgery, cautery, hyfrecator, radio-surgery, laser (rarely scalpel)
116
minor surgery treatments for ingrown toenails
cryosurgery (sometimes), hyfrecator (sometimes), radio-surgery, scalpel, laser
117
minor surgery treatments for keratosis
cryosurgery, cautery, hyfrector, radio-surgery, scalpel, laser
118
minor surgery treatments for basal cell carcinoma
cryosurgery, cautery, hyfrector, radio-surgery, scalpel, laser
119
furuncles and carbuncles
local staph infections--begin as infection of hair follicle
120
furuncle vs carbuncle
furuncle (singular) carbuncle (multiple)
121
paronychia
staph infection of the nail
122
nail removal anesthesia
nerve block-best option for complete avulsion.
| field block
123
can epinephrine be used for nail removal
no
124
blade used for nail avulsion
flat-spatulated
125
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.
126
fish hook removal
anesthetize, push hook through, cut off tip and back hook out.
127
what percent of bites are from dogs/ cats/other animals
90/5/5
128
what bacteria is common to animal bites?
pasturella multocida (gram negative)
129
what should be treated as if rabies were present?
all animal bites
130
what type of wounds are animal bites?
dirty
131
where do most human bites occur
over the metacarpophalangeal joint on dorsum of hand (clenched fist)
132
bacteria most associated with human bites
eikenella corrodens
133
contraindications for snake bite treatment
cryotherapy, incision and suction, tourniquets/constrictive bands
134
what is frostbite
a form of peripheral vascular disease due to exposure to cold
135
frostbite treatment
internal and external rewarming
external with dry warmth
internal with warm liquid
136
treatment of vesicles or blebs from frostbite
transfer to hopsital or ED
137
burns of what extent are a medical emergency?
adults 15%
| children 10%
138
first degree burn
epidermis only (sunburn)
139
second degree burn
most frequent burn, capillary wall destruction and edema and bleb formation
140
third degree burn
destructive tissue loss with subsequent scarring. referral to ED
141
rectum anatomy
begins at S3 level, descends along sacrum and coccyx and ends at upper pelvic diaphragm, 12-15cm long
142
anal canal anatomy
begins at anorectal junction, 3-4cm long, terminates at anal verge.
143
musculature and innervation of anorectal region
```
inner tube (visceral smooth muscle-autonomic control)
outer tube (skeletal muscle-somatic control)
```
144
dentate line
midpoint of anal canal-undulating demarcation, 2cm from anal verge.
145
columns of morgagni
"pleated" longitudinal fold above the dentate line
146
crypts of morgagni
at the base of the columns of morgagni (can have obstruction and abscess formation
147
internal sphincter innervation
involuntary-sympathetics (motor) and parasympathetics (inhibitory)
148
bright red blood that drips into toilet and is free from stool
associated with bleeding internal hemorrhoids
149
blood on tissues
associated with anal fissures or abrasion of anal canal
150
melena
pathologic processes higher in GI tracts
151
blood and mucous in stool
low lying carcinoma or more commonly UC and crohns
152
skin tag
area of hypertrophied cutaneous tissue adjacent to anus
153
skin tag location (anus)
posterolateral quadrant
154
sin tag etiology
```
old external hemorrhoids
anal fissure or fistula
crohns disease
condyloma acuminata
anal neoplasia
pruritus ani
previous anorectal surgery
```
155
symptomatic skin tag treatment
ointments, hot sitz baths, removal
156
skin tag removal options
cryosurgery, laser or electrosurgery
157
pruritus ani
perianal itching
158
hemorrhoids
"sliding down" of the thick, vascular cushions within the anal lining.
159
hemorrhoid locations
left lateral, right lateral and posterolateral
160
percent of population over 50 affected by hemorrhoids
50-70%
161
external hemorrhoids
dilated venules of the inferior hemorrhoidal plexus below the dentate line.
162
internal hemorrhoids
symptomatic, swollen submucosal vascular tissue above the dentate line.
163
first degree hemorrhoid
no protrusion or bulge into lumen of rectal canal
164
second degree hemorrhoid
protrude at stool and reduce spontaneously
165
third degree hemorrhoid
produce at stool and must be manually reduced
166
fourth degree hemorrhoid
protrude at stool and cannot be reduced
167
mixed hemorrhoids
elements of internal and external hemorrhoids present
168
strangulated hemorrhoids
prolapsed hemorrhoids, due to spasm of sphincter, lose blood supply and will become gangrenous
169
definitive examination of hemorrhoids
anoscopy
170
proctosigmoidscopy
to visualize rectum and lower colon and exclude carcinoma and IBD
171
first degree hemorrhoid tx
diet change, stool softeners, suppositories and sitz baths
172
rubber band ligature
for first degree internal hemorrhoids not relieved by diet
173
sclerotherapy
injection of solution (5% phenol in vegetable oil) for hemorrhoids not relieved by diet
174
manual dilation of anus
to overcome obstruction due to constricting bands
175
cryotherapy for hemorrhoids problems
profuse foul smell for 2 weeks after until necrosed tissue sloughs off
176
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
177
fissure in ano
painful linear ulcer in anal canal from just below dentat line to anal level
178
fissure in ano sx
pain after defecation
frank bleeding
constipation
dysuria
179
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
180
sentinel pile
swelling at lower end of fissure and swelling and fibrosis at proximal end in anal valves
181
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
182
blue cyanotic hue of perianal skin
crohn's disease
183
irradiation proctitis
iatrogenic condition of patients undergoing radiation therapy. most commonly related to cervical cancer.
184
tuberculosis affecting anorectum
caseating granuloma and acid fast bacilli in lesion
185
condylomata acuminata
most commonly seen disease of the anorectum. papilloma virus.
186
condylomata lata
secondary syphilis
187
neoplasms of the anorectal canal
squamous cell carcinoma (MC)
basal cell carcinoma
bowen's disease
perianal paget's disease
188
squamous cell carcinoma appearance
rolled everted edges and central ulceration
189
fistula
abnormal communication between any two epithelial surfaces
190
anal fistula
abnormal communication between the anal canal and perianal skin
191
anal fistula origin
crypts of morgagni (90%)
192
horseshoe fistula
upward tracking fistula that goes circumferentially around the anus
193
abscess vs fistula
abscess-acute manifestation
| fistula-chronic situation
194
ddx for fistula
```
bartholin gland abscess
sebaceous cyst
TB
osteomyelitis of the bony pelvis
fissure
urethroperineal fistula
```
195
most common benign condition of the large bowel
polyps
196
appearance of polyps
can be sessile, pedunculated or villous
197
which polyps are most likely malignant
villous
198
treatment for polyps
excisional biopsy
199
povidone-iodine surgical scrub
wound cleansing agents (wound periphery and hands)
200
povidone-iodine without detergent
wound cleansing agents (wound periphery)
201
chlorhexidine
hand cleanser
| alternative wound cleanser
202
pluronic F-68
face cleaner
203
hexachloropene
alternative hand cleanser
| teratogenic
204
ganglia
cystic swelling near joint capsules and tendon sheaths
205
ganglia tx
not covered by chiros
206
benign tumors
palpable and usually non-tender mobile encapsulations
207
malignant tumors
basal cell c
squamous cell c
melanoma
208
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
```
209
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
210
squamous cell tx
excisional biopsy
211
melanoma
```
most dangerous
least frequent
nevus shaped
jet black
occasionally has visible vascularization
may ulcerate or bleed
```
212
dexon, dexon plus and dexon S
synthetic absorbable sutre
213
vicryl, coated vicryl
synthetic absorbable sutre
214
dacron, mersilen
braided silk or polyester
215
dermalon, ethilon, nurolon
nylon sutures
