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X Emergency Med Exam 3 > Skin and Soft Tissue Disorders > Flashcards

Skin and Soft Tissue Disorders Flashcards

1
Q

Wounds prone to tetanus

A

Longer than 6 hrs old
Deep (>1 cm) wounds
Grossly contaminated
Avulsion/puncture/crush

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2
Q

Tetanus vaccinations

A

DTap: 2, 4 and 6 months, 15-18 months and 4-6 yrs
Tdap: 11-12 yrs, then once for adults and then Td Q 10 yrs

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3
Q

Risk factors for impaired wound healing

A 
Infection
Smoking
Malnutrition
Immobilization
Diabetes
Vascular disease
Immunosuppressive therapy
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4
Q

What to remember about organisms of animal bites?

A

Treat polymicrobially because mixture of flora of animal and human skin

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5
Q

Wounds seen with cat bites

A

Deep due to long slender teeth (or claws)

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6
Q

Punctures below periosteum with cat bites

A

May lead to osteomyelitis and septic arthritis

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7
Q

Categories of human bites

A 
Occlusive wounds (intent to harm)
Clenched fist or fight bites (due to teeth scraping when hit etc)
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8
Q

Why do you measure human bite marks?

A

If maxillary inter-canine distance is >2.5 cm think adult bite and child abuse

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9
Q

When to have surgical consult with bite wounds

A

Deep penetrating wounds to bones, tendons, joints or other major structures
Complex facial lacerations
Wounds associated with neurovascular compromise
Wounds with complex infections

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10
Q

When to use prophylactic abx with bite wounds

A

Deep puncture wounds
Moderate to severe wounds with associated crush injury
Underlying venous and or lymphatic compromise
Wounds on hands, genitalia, face or in close contact with bone/joint
Wounds needing closure
Compromised host

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11
Q

Most common cause of plantar puncture

A

Stepping on a nail

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12
Q

Management for plantar puncture

A 
X-ray
Cleansing and remove foreign body
Close by secondary intent
Tetanus
Keep clean and warm for infection
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13
Q

When to x-ray with plantar puncture

A 
Inability to visualize interior of wound
Deep wounds caused by glass
Pt believes there is retained object
Object is small, breakable or brittle
Object can be seen or felt beneath skin surface
Severe wound pain
Persistent localized pain over wound
Painful mass or discoloration under skin
Missing portion of object
Injury went through rubber shoe
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14
Q

Indications for closure with lacerations

A 
Extension into subQ
Decrease healing time
Reduce likelihood of infection
Decrease scar formation
Repair loss of structure or function
Improve cosmesis
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15
Q

Contraindications for closure with lacerations

A 
Contaminated wounds
Wounds greater than 12 hrs old
Presence of FB
Wounds involving tendons, nerves, arteries
Can't get bleeding under control
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16
Q

Complications of closure of a laceration

A 
Infection
Loss of function
Wound dehiscence (wound ruptures along incision)
Scars (keloid formation)
Loss of cosmesis
Tetanus
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17
Q

Classifications of wounds

A

Clean
Clean-contaminated
Contaminated
Infected

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18
Q

Clean wound

A

Surgical incisions

No involvement of GU, GI or respiratory tracts

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19
Q

Clean-contaminated wound

A

Involvement of GU, GI or respiratory tracts

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20
Q

Contaminated wound

A

Gross spillage into surgical wound (bile, stool)

Traumatic wounds

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21
Q

Infected wound

A 
Established infection (I&D abscess)
Gross contamination
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22
Q

Classification of wound closure

A

Primary intention
Secondary intention
Delayed primary intention

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23
Q

What is primary intention closure?

A

All layers closed
Best chance for minimal scarring
Clean/clean-contaminated wounds

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24
Q

What is secondary intention closure?

A

Deep layers closed (heals inside out)
Superficial layers left to granulate
Can leave wide scar
Requires frequent wound care

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25
What is delayed primary intention closure?
Deep layers closed primarily | Superficial layers closed in 4-5 days after infection is not concern
26
Absorbable or nonabdorbable: vicryl?
Absorbable
27
Absorbable or nonabdorbable: PDS (polydioxanone)
Absorbable
28
Absorbable or nonabdorbable: prolene
Nonabsorbable
29
Absorbable or nonabdorbable: nylon?
Nonabsorbable
30
Absorbable or nonabdorbable: chromic gut?
Absorbable
31
Types of suturing methods
Simple interrupted Vertical mattress (lies in plane perpendicular to skin, for deep wounds to eliminate dead space) Horizontal mattress (lies in plane parallel to skin, useful for flaps or wounds under tension) Continuous Subcuticular (for surgical or clean wounds, absorbable suture)
32
What are Langer's lines?
Skin tension lines that indicate orientation of collagen fibers Lacerations that run at right angles to the lines tend to gape
33
Post suture care
``` Keep the site clean and dry Elevate Look for signs of infection Activity restriction Analgesia Remove eventually ```
34
Shortest body part and longest body part for suture removal
Shortest: face/ear Longest: Back/foot/scalp
35
Do small, uncomplicated lacerations need abx?
No, not for prophylaxis
36
Laceration risk factors for infection
``` Wound >12 YO, especially on hands Bites Crush wounds Contaminated wounds Avascular areas Wounds involving joint spaces, tendon or bone History of valvular disease Immunocompromised pts ```
37
Most important means to decrease infection risk
Irrigation (others are debridement and FB removal)
38
Do you need to shave hair before suturing?
No b/c can increase risk of infection and leave particles in wound
39
When to recheck sutured wounds
24-48 hrs (highly contaminated wounds need recheck in 48-72 hrs)
40
What is cellulitis?
Nonnecrotizing inflammation of the skin and subcutaneous tissues Does not involve fascia or muscles Infection without formation of abscess (nonpurulent), purulent drainage or ulceration
41
What does cellulitis look like?
Localized pain, swelling, tenderness, erythema and warmth Maybe regional LAD Malaise, fever and/or chills
42
Cellulitis etiology of immunocompetent pts
A strep or S aureus
43
Cellulitis etiology of immunocompromised pts
Nontraditional (pseudomonas, proteus, serratia, enterobacter, citrobacter)
44
4 cardinal signs of infection
Erythema Pain Swelling Warmth
45
Signs/sxs of deep soft tissue infection
``` Violaceous bullae Cutaneous hemorrhage Skin sloughing Skin anesthesia Rapid progression Gas in tissue *emergent surgical eval ```
46
Outpatient care of soft tissue infection
(mild, local sxs without evidence of systemic disease) Limb elevation to reduce swelling Empiric abx Follow up in 48-72 hrs
47
When would you do inpatient care with a skin infection?
Facial cellulitis of odontogenic origin Immunocompromised pts Orbital cellulitis Pts with comorbidities (lymphedema, cardiac/hepatic/renal failure) Cellulitis on more than 1/4 of an extremity
48
Most likely pathogen of cellulitis without drainage or abscess
Strep (duration tx 5 days)
49
Abx for mild cellulitis
Penicillin, cephalosporin, dicloxacillin or clindamycina
50
Abx for moderate cellulitis
Penicillin, ceftriaxone, cefazolin or clindamycina
51
Cause of recurrent cellulitis
Usually due to venous or lymphatic obstruction | Penicillin or Erythromycin BID for 4-52 wks
52
When is there an increased risk for abscess?
Staph aureus carrier Break in skin Immunocompromised
53
When to refer for surgical drainage with an abscess
``` Perirectal abscess Anterior and lateral neck abscesses Hand abscesses Abscesses adjacent to vital nerves or blood vessels (facial nerve, carotid artery or femoral artery) Breast abscesses near areola and nipple ```
54
Home care for abscess
Follow up in 24-48 hrs Change packing every 24 hrs Wound washed in shower with soap and water Bath with chlorhexidine daily (recurrent) (will do empiric abx to treat MRSA)
55
Causes of recurrent abscess (MRSA)
Likely due to colonization | 5 day decolonization regimen (BID nasal mupirocin, chlorhexidine washes, decontaminate)
56
Organism most common in first few days after burn injury
Staph aureus
57
Clinical features of burn wound infection
Rapid change in condition: fever, increased pain, feeding intolerance
58
What is necrotizing fasciitis?
Infection of deep soft tissues that results in progressive destruction of muscle fascia and overlying subQ fat Spares muscle?
59
Pathogens of necrotizing fasciitis
Polymicrobial: aerobic and anaerobic Monomicrobial: GAS or beta-hemolytic strep
60
Pathogens of Fournier's gangrene
Polymicrobial: E coli, Klebsiella, enterococci Anaerobes: bacteroides, fusobacterium, clostridium
61
What is Fournier's gangrene?
Infection of the perineum often involving scrotum
62
Features of Fournier's gangrene
Severe pain starting in abd anterior wall and migrates to gluteal muscles, scrotum and penis Edema outside the skin, blisters, crepitus Fever, tachycardia, hypotension
63
Tx of Fournier's gangrene
Surgical debridmenet | Broad spectrum abx
64
Option to anesthetize
Lidocaine with epi
65
Blade for I&D
11 blade

X Emergency Med Exam 3 (5 decks)

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