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Surgery Clerkship > Skin > Flashcards

Skin Flashcards

1
Q

What is the implication of crepitus?

A

Gas in the tissues: presence of gas-forming organisms

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2
Q

What are the risk factors for NSTI?

A
  • Decreased immunity
  • Decreased tissue perfusion
    Ex: DM, malnutrition, IVDU, obesity, chronic alcohol use, CLL, chronic steroid use, renal failure, PAD, cirrhosis
  • Traumatic extremity wounds with contamination OR post surgically
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3
Q

What is the implication of bullae?

A

Partial tissue death within layers of skin that allow for collection of fluid between layers

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4
Q

What is implication of violaceous skin?

A

Violet or purple discoloration 2/2 ischemia

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5
Q

What are the hard signs of NSTI? What percent of patients have them?

A 
Hypotension
Crepitus
Skin necrosis / bullae
Gas on x-ray
< 50%
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6
Q

How to distinguish between cellulitis and NSTI?

A
  • Difficult: need high level of suspicion

- Use Lab Risk Indicator for Nec Fasciits (LRINEC) to help distiguish

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7
Q

What components are in the LRINEC for NSTI?

A

CRP, WBC (high), Hb, Na (low), Cr, glucose

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8
Q

Why is it important to distinguish between cellulitis and NSTI?

A

Tx: cellulitis is ABx and NSTI is emergent surgical debridement

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9
Q

What is the spectrum of NSTI (location)?

A

Skin/SubQ: necrotizing cellulitis
Fascia: necrotizing fasciitis
Muscle: Necrotizing myositis

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10
Q

What are the 3 types of NSTI?

A

Type I: polymicrobial
Type II: Group A Strep
Type III: Clostridial myonecrosis: Clostridium perfringens

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11
Q

What other term is used for necrotizing myositis?

A

Gas gangrene

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12
Q

What is the implication of culturing Clostridium septicum from the wound?

A
  • Can lead to gas gangrene

- Associated with occult malignancies (colon cancer)

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13
Q

What is the term for NSTI that involves scrotum/perineum?

A

Fournier’s gangrene

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14
Q

What are initial management steps of NSTI?

A

IV fluids
Broad spectrum IV AB
Aggressive surgical debridement

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15
Q

How do you determine how much tissue to debride in NSTI?

A

Take all sub tissues that show any evidence of infection: must see healthy bleeding tissue! Cannot leave any borderline tissue

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16
Q

What if extensive muscle necrosis is found during surgery for NSTI?

A

Amputation may be necessary

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17
Q

What are intraoperative findings that confirm NSTI?

A
  • Murky fluid (dishwasher)
  • Gray discoloration of fascia
  • Lack of bleeding from fascia
  • Fascia may separate from muscle too easily w/o normal resistance
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18
Q

What is the role of 2nd look operation?

A

Schedule 24 horus after initial debridement to make sure infection is truly gone (may need to do several times)

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19
Q

What if NSTI is highly suspected but diagnosis is uncertain?

A

Do surgical exploration

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20
Q

Is imaging beneficial for NSTI diagnosis?

A
  • Plain xrays: may show gas

- CT: can show asymmetric fascial thickening, gas tracking along fascial planes or abscess

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21
Q

What is mortality risk of NSTI?

A

25%

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22
Q

What is an emerging therapy for NSTI?

A

Hyperbaric oxygen: reduces mortality

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23
Q

How can we differentiate melanoma from a benign nevus?

A 
ABCDEs:
Asymmetry
Border irregularity
Color change
Diameter > 6mm
Evolution
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24
Q

What risk factors for skin cancer are common to SCC, BCC and melanoma?

A
  • Excess exposure to UV light, especially UVB

- Immunosuppression

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25
Q

What factors during childhood/teen years are associated with increased risk of skin cancer?

A

Blistering sunburn

Tanning salon

26
Q

What does hair growth on a skin lesion suggest?

A

Benign: melanomas destroy hair follicles

27
Q

What is the ugly duckling sign?

A

Any skin lesion that looks out of place/different = ugly duckling: should biopsy!

28
Q

What is important about chronic skin inflammation when evaluating from skin lesions?

A

Risk factor for SCC: can develop in chronic open burn wounds, chronic venous ulcers, and long standing skin infections

29
Q

What to do with chronically non-healing wounds?

A

Biopsy: rule out malignancy

30
Q

What areas of the skin are melanomas are most likely to occur in non-white ethnicities?

A

Af Am, Asian and Hawaiian populations: occur on areas of non exposed skin with less pigment: palms, soles, mucous membranes and nail regions

31
Q

What is the most common site of melanoma in men vs. women?

A

Men: the back
Women: the legs

32
Q

What is the most common site of digital melanoma?

A

Great toe: amputate and sentinel nodes

33
Q

Does the regular use of SPF protection reduce the risk of skin cancer?

A

Yes: SPF 15 reduces the risk of SCC and melanoma by about 50%

34
Q

Where does melanoma arise from?

A

Melanocytes

35
Q

What is the order of most common to least for skin cancer?

A

BCC > SCC > melanoma

36
Q

What is the most common precancerous skin lesion?

A

Actinic keratosis: rough scaly epidermal lesion in an area of chronic sun exposure

37
Q

What is Bowen’s disease?

A

squamous cell carcinoma in situ: well defined erythematous plaque covered by adherent scaly yellow crust (does not metastasis)

38
Q

What is the 5 year survival of melanoma > 4.0mm thickness?

A

50%

39
Q

What is the 5 year survival of melanoma < 0.75mm thickness?

A

95-100%

40
Q

What is the metastatic risk of BCC, SCC and melanoma?

A

BCC: no mets usually
SCC: do metastasize, but less likely than melanoma
Melanoma: to skin > lung, liver, brain and bone

41
Q

What is the most common metastasis to small bowel?

A

melanoma

42
Q

What is superficial spreading melanoma?

A

Most common type: long horizontal growth phase before vertical (better prognosis)

43
Q

What is lentigo melanoma?

A

Lentiginous proliferation: tumor remains at the junction (best prognosis)

44
Q

What is acral lentiginous melanoma?

A

In subungual, sole or palm location, common in groups of color

45
Q

What is nodular melanoma?

A

Worst prognosis: rapid vertical growth and increased metastatic potential

46
Q

Which type of melanoma is not related to UV light exposure?

A

Acral lentiginous

47
Q

How do we stage melanoma?

A

Breslow depth: vertical height of melanoma

48
Q

In a suspicious skin lesion, what is the next step in management?

A

Small: excision biopsy

If larger: incisional biopsy (punch biopsy)

49
Q

Once diagnosis of melanoma is established, what additional studies should be done?

A

CXR
CBC
LFTs
LDH: prognostic indicator, may demonstrate liver mets

50
Q

What if palpable lymph nodes are present in setting of melanoma?

A

CT scan or chest, abdomen pelvis

PET scan

51
Q

What are poor prognostic indicators for melanoma patients?

A

Thicker lesions
Ulceration
Location on trunk
Male gender

52
Q

What is primary treatment for BCC/SCC skin cancers?

A

Excisional biopsy

Can use Mohs for tissue sparing in cosmetically sensitive areas

53
Q

What type of surgical margins are needed for BCC vs. SCC?

A

BCC: 3-5mm
SCC: 5-10mm

54
Q

If margins are positive, what is necessary in skin cancer?

A

Must re-excise to clear!

55
Q

How do we manage melanoma surgically?

A
  • Diagnose via punch or excision biopsy
  • Re-excise for clear margins based on Breslow depth
  • Selective SLNB based on Breslow depth
56
Q

Who gets lymph node dissection with melanoma?

A

Clinically palpable disease

OR positive sentinel lymph node biopsy

57
Q

What is the follow-up protocol for melanoma?

A
  • PE at 3-6 month intervals for first 3 years
58
Q

Do we use Mohs for melanoma? Why or why not?

A

No: difficulty with preparing frozen sections for visualization of melanocytes (need immunohistochemial staining)

59
Q

When we suspect melanoma, can we use shave biopsy?

A

No: cannot assess depth of lesion

60
Q

What 2 types of melanoma do not follow ABCDE rules?

A

Nodular: berry like lesion that grow vertically

Amelanotic melanoma: have no pigment

Surgery Clerkship (16 decks)

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