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EMED Unit 3 > Skin and Soft Tissue Disorders > Flashcards

Skin and Soft Tissue Disorders Flashcards

1
Q

When should people receive tetanus vaccinations?

A

DTaP
• 2, 4, and 6 months
• 15-18 months
• 4-6 years

Tdap
• 11-12 years
• Once for adults
• Td q10 years

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2
Q

Secondary prevention of tetanus includes…

A

Wound cleansing and debridement

Tetanus toxoid as indicated and TIG when indicated

Vaccination if last Td was >5 years ago

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3
Q

Vaccination protection from tetanus lasts _______

A

10 years

Common secondary prevention if vaccination >5 years ago

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4
Q

What types of wounds are prone to tetanus?

A

Longer than 6 hours old

Deep (>1 cm) wounds

Grossly contaminated

Avulsion/puncture/crush

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5
Q

Risk factors for impaired wound healing

A 
Infection
Smoking
Malnutrition
Immobilization
Diabetes
Vascular disease
Immunosuppressive therapy
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6
Q

_____ cause 1% of all ED visits

A

Animal bites

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7
Q

What type of animal is most likely to bite you and send you to the ED?

A

DOGS - 60-90% of animal bites

Cats - 5-20%

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8
Q

The microbiology of animal bites is composed of ________ and ______

A

Oral flora of biting animal

Human skin flora

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9
Q

What microorganisms are most likely to show up in an animal bite?

A

PASTEURELLA (50% of dog bites and 75% of cat bites)

Staphylococcus

Streptococcus

Anaerobes (bacteroides and fusobacterium)

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10
Q

Dog or cat bite:

Animal frequently knows the human they bite

A

Dog

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11
Q

60-70% of dog attacks on children <5 involve…

A

The head and neck

Also on 50% of children 5-10

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12
Q

89% of cat bites are _______

A

Provoked —> wounds from teeth and claws

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13
Q

What kinds of wounds do cat bites cause?

A

Long slender teeth —> deep wounds

2/3 involve the upper extremities

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14
Q

Punctures due to cat bites that penetrate below the periosteum may lead to …

A

Osteomyelitis or septic arthritis

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15
Q

What are the two categories of human bites?

A

Occlusive wounds

Clenched fist (fight bites)

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16
Q

What pathogens are most likely in human bites?

A

Eikenella corrodens (gram (-) anaerobe)

Group A strep

Staphylococcus

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17
Q

What is a key thing you need to do when dealing with a human bite?

A

Measure that shit

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18
Q

If the maxillary inter-canine distance is > ______ it is likely an adult bite

A

> 2.5cm

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19
Q

What steps are involved in the management of bite wounds?

A 
Hemorrhage control
X-ray
Anesthesia
Inspection
Surface cleaned with POVIDONE IODINE
Copious irrigation to clean the depths
Debridement of devitalized tissues
Exploration for foreign bodies and deeper damage
Surgical consult if indicated
Primary closure for dog bites
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20
Q

Which bite wounds require surgical consult?

A

Deep, penetrating wounds to the bones, tendons, joints, or other major structures

Complex facial lacerations

Wounds associated with neurovascular compromise

Wounds with complex infections

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21
Q

When are prophylactic antibiotics indicated for 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 requiring closure

Compromised hosts

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22
Q

Most common MOA for plantar punctures

A

Stepping on a nail

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23
Q

How do you manage plantar punctures?

A 
X-ray
Cleansing
Removal of foreign body
Closure by secondary intent
Tetanus
Keep clean and watch for SSx of infection
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24
Q

When should you x-ray a plantar puncture?

A

Inability to completely visualize the interior of the wound
Deep wounds caused by glass
Patient believes there is a retained object
Object is small, breakable, 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 the object
Injury went through rubber shoe

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25
Q

There’s only one fucking slide on needle stick injuries. What did it say?

A

Immediately cleanse the exposed site (soap, water, alcohol)

Report and document

Determine HIV status of source and person with the stick (also Hep B and Hep C)

Post exposure prophylaxis

Prevention of spread

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26
Q

Indications for laceration closure

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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27
Q

Contraindications for laceration closure

A

Contaminated wounds

Wounds greater than 12 hours old

Presence of foreign body

Wounds involving tendons, nerves, or arteries

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28
Q

What are some possible complications of laceration closure?

A

Infection

Loss of function

Wound dehiscence

Scars, including keloid formation

Loss of cosmesis

Tetanus

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29
Q

Name the wound classification:

Surgical incisions w/o involvement of GU, GI, or respiratory tracts

A

Clean

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30
Q

Name the wound classification:

Involvement of GU, GI, or respiratory tracts

A

Clean-contaminated

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31
Q

Name the wound classification:

Gross spillage into surgical wounds (bile, stool)

A

Contaminated

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32
Q

Name the wound classification:

Traumatic wounds

A

Contaminated

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33
Q

Name the wound classification:

I&D abscess

A

Infected

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34
Q

Name the wound classification:

Gross contamination

A

Infected

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35
Q

What types of wounds are considered clean?

A

Surgical incisions

No involvement of GU, GI, or respiratory tracts

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36
Q

What types of wounds are considered clean-contaminated?

A

Involvement of GU, GI, respiratory tracts

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37
Q

What types of wounds are considered contaminated?

A

Gross spillage into surgical wound (bile stool)

Traumatic wounds

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38
Q

What types of wounds are considered infected?

A

Established infection (I&D abscess)

Gross contamination

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39
Q

Name the wound closure classification:

All layers closed

A

Primary intention

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40
Q

Name the wound closure classification:

Best chance for minimal scarring

A

Primary intention

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41
Q

Name the wound closure classification:

Used for clean and clean-contaminated wounds

A

Primary intention

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42
Q

Name the wound closure classification:

Deep layers closed and superficial layers left to granulate

A

Secondary intention

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43
Q

Name the wound closure classification:

Can leave wide scar

A

Secondary intention

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44
Q

Name the wound closure classification:

Requires frequent wound care

A

Secondary intention

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45
Q

Name the wound closure classification:

Deep layers closed primarily and superficial layers closed in 4-5 days after infection is no longer a concern

A

Delayed primary intention

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46
Q

What HPI questions are most important in working up a laceration?

A

How, when, where injury occurred

Tetanus status

Chronic illness hx

47
Q

PE for lacerations

A

Type of wound

Location, extent, and contamination level

Careful neuro exam

Evaluation for concomitant injuries

48
Q

Laceration management involves…

A

Irrigation of wound

Clean wound

Closure if appropriate

Tetanus if appropriate

49
Q

What types of suture are absorbable?

A

Vicryl (60-90 days)

Polydioxanone (PDS - 6 months)

Chronic gut

50
Q

What types of suture are non-absorbable?

A

Prolene

Nylon

51
Q

What is the caution for using nylon sutures

A

Reactive and may wick microorganisms into the wound

52
Q

Name the suturing method:

3-10mm in length and the same distance apart
Frequently used to close skin lacs

A

Simple interrupted

53
Q

Name the suturing method:

Lies in plane perpendicular to skin

A

Vertical mattress

54
Q

Name the suturing method:

Used for deep wounds to help eliminate dead space

A

Vertical mattress

55
Q

Name the suturing method:

Lies in plane parallel to skin

A

Horizontal mattress

56
Q

Name the suturing method:

Useful in flaps or wounds under tension

A

Horizontal mattress

57
Q

Name the suturing method:

Can be performed quickly and if locked provides tighter closure

A

Continuous

58
Q

Name the suturing method:

Used often for surgical or clean wounds but must use absorbable suture

A

Subcuticular

59
Q

Skin tension lines that indicate orientation of collagen fibers

A

Langer’s Lines

60
Q

Why do we give shit about langer’s lines?

A

Lacerations that run at right angles to lines tend to gape

61
Q

What is the best way for patients to keep suture site clean and dry?

A

No contact with water for 48 hours

Soap and water for wound care thereafter, dry well

62
Q

What are the recommendations for post suture care?

A

Keep site clean and dry

Elevate if possible

Education patient to observe for signs of infection

Consider activity restriction

Analgesia

Removal

63
Q

Signs of infection to watch for post suturing

A

Pain

Swelling

Redness

Drainage

64
Q

When should sutures be removed:

Scalp

A

7-14 days

65
Q

When should sutures be removed:

Face

A

5 days

66
Q

When should sutures be removed:

Ear

A

4-5 days

67
Q

When should sutures be removed:

Chest/abdomen

A

8-10 days

68
Q

When should sutures be removed:

Back

A

12-14 days

69
Q

When should sutures be removed:

Arm/leg

A

7/8-10 days

70
Q

When should sutures be removed:

Hand

A

8-10 days

71
Q

When should sutures be removed:

Fingertip

A

10-12 days

72
Q

When should sutures be removed:

Foot

A

12-14 days

73
Q

Risk factors for infection of lacerations (abx indicated)

A

Wound >12 hours, esp on hands

Bites

Crush wounds

Contaminated wounds

Avascular areas (ie ear)

Wounds involving joint spaces, tendon, or bone

Hx of valvular heart disease

Immunocompromised patients

74
Q

Does hair need to be shaved off prior to suturing a hairy area?

A

No

Shaving can increase risk of infection and leave particles in the wound

75
Q

What is the most important means to decrease infection risk for lacerations?

A

Irrigation

Debridement and foreign body removal if necessary

76
Q

Assessment of minor wounds should include…

A 
Determination of allergies
Status of tetanus
MOI
FB presence
Extent of wound
Neurovascular or tendon compromise
Cosmetic significance
77
Q

When should all sutured wounds be re-checked?

A

24-48 hours

Highly contaminated wounds rechecked in 48-72 hours

78
Q

What are some examples when absorbable sutures may be preferred?

A

Pediatric/elderly patients in whole suture removal may be difficult

Oral mucosa (chromic gut or vicryl)

Under splints or casts

79
Q

What is the definition of cellulitis?

A

Non-necrotizing inflammation of the skin and subcutaneous tissues

Usually related to acute infection that does not involve the fascia or muscles

80
Q

Cellulitis is characterized by …

A

Localized pain, swelling, tenderness, erythema, and warmth

81
Q

Most common causative agents of cellulitis in immunocompetent patients

A

Strep A

Staph aureus

82
Q

Most common etiology of cellulitis in immunocompromised patients

A 
Pseudomonas
Proteus
Serratia
Enterobacter
Citrobacter
83
Q

What are the four cardinal signs of infection (one more time)?

A

Erythema
Pain
Swelling
Warmth

84
Q

Common presentation of cellulitis

A

Site is red, hot, swollen, and tender

May have regional LAD

Malaise, fever, and/or chills

85
Q

SSx of deep soft tissue infection (severe infection)

A 
Violaceous Bullard
Cutaneous hemorrhage
Skin sloughing
Skin anesthesia
Rapid progression
Gas in tissue

All of these require emergent surgical evaluation

86
Q

When is outpatient care of cellulitis indicated?

A

Mild, local symptoms w/o evidence of systemic disease

87
Q

Outpatient care of cellulitis should include…

A

Limb elevation to reduce swelling

Empiric abx

Follow up with in 48-72 hours

88
Q

When is inpatient care of cellulitis indicated?

A

Facial cellulitis of odontogenic origin

Immunocompromised patients

Orbital cellulitis

Patient with comorbidities (lymphedema, cardiac, hepatic, or renal)

Cellulitis affecting more than 1/4 of an extremity

89
Q

Mainstay of treatment for cellulitis

A

Beta-lactams (Amoxicillin, augmentin)

90
Q

When are cephalosporins used to treat cellulitis?

A

Cephalexin if strep or MRSA suspected

Ceftriaxone if gram (-) organisms

91
Q

When are macrolides used to treat cellulitis?

A

In PCN allergic patients

NOT effective against MRSA

92
Q

Abx treatment of cellulitis should be ______ in duration

A

10-14 days

93
Q

_____ is the most likely pathogen in wounds without drainage or abscess

A

Strep

94
Q

Recommended abx for mild cellulitis

A

Penicillin
Cephalosporin
Dicloxacillin
Clindamycin

95
Q

Recommended abx for moderate cellulitis

A

Penicillin
Ceftriaxone
Cefazolin
Clindamycin

96
Q

Recurrent cellulitis is usually due to…

A

Venous or lymphatic obstruction

Use penicillin or erythromycin BID for 4-52 weeks

97
Q

Increased risk factors for abscess formation

A

Staph aureus carrier

Break in skin

Immunocompromised

98
Q

What types of abscesses require a surgical referral?

A

Perirectal abscesses

Anterior and lateral neck abscesses

Hand abscesses

Abscesses adjacent to vital nerves or vessels (facial nerve, carotid artery, femoral artery)

Breast abscesses near areola and nipple

99
Q

Patients treated for abscesses should follow up in _____

A

24-48 hours

100
Q

If an abscess if packed, how often should the packing be changed?

A

Every 24 hours

101
Q

Patients with recurrent abscesses should do what at home?

A

Bath with chlorhexidine daily

102
Q

What is the decolonization regimen for MRSA?

A

5 days of the following:
• BID nasal mupirocin
• Daily chlorhexidine washes
• Daily decontamination of personal items

103
Q

Most common organism to cause infection in the first few days after a burn injury

A

Staph aureus

104
Q

What are the signs of an infection in a burn patient?

A

Rapid change in condition

Fever, increased pain, feeding intolerance

105
Q

How do you manage burn wound infections?

A

Avoid hyperthermia

Culture

Systemic abx with sepsis or septic shock
• Pipercillin/tazobactam or Carbapenem
• Consider adding vancomycin with suspected MRSA

106
Q

Patients with burns who develop cellulitis should be treated with…

A

IV Cefazolin or clindamycin or vancomycin if MRSA suspected

107
Q

Infection of the deep soft tissues resulting in progressive destruction of muscle fascia and overlying sub-q fat

A

Necrotizing fasciitis

108
Q

Why does necrotising fasciitis appear smaller on the surface that the infection actually is?

A

B/c it spreads along the fascia (deep)

109
Q

Pathogens involved in necrotising fasciitis

A

Can be either poly or monomicrobial

Poly —> aerobic and anaerobic

Mono —> GAS or beta-hemolytic strep

110
Q

Is fournier’s gangrene mono- or polymicrobial

A

POLY

E. coli, Klebsiella, and Enterocci often involved
Also, bactericides, fusobacterium, clostridium

111
Q

Infection of the perineum often involving the scrotum, characterized by severe pain starting in the anterior abdominal wall and migrating to the gluteal muscles, scrotum, and penis

A

Fournier’s Gangrene

112
Q

How is fournier’s gangrene treated?

A

Aggressive surgical debridement, broad spectrum abx

113
Q

When should a burn patient be transferred to a burn center?

A

Partial-thickness burns >10% of TBSA

Third-degree burns in any age group

Burns to face, hands, feet, genitalia, perineum, major joints

Electrical burns (including lightening)

Chemical burns

Inhalation injury

Those with preexisting medical disorders that could complicate management

Those with concomitant trauma

EMED Unit 3 (5 decks)

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