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Derm Surg questions > Skin Surgery > Flashcards

Skin Surgery Flashcards

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Dermatology Board Prep flashcards
1
Q

Max dose of lidocaine without epi

A

4.5 mg/Kg

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2
Q

Max dose of lidocaine with epi

A

7.5 mg/Kg

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3
Q

Max dose of lidocaine for children

A

half the dose of adults

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4
Q

what Electrosurgery uses a direct current to heat a probe

A

electrocautery

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5
Q

list two monoterminal forms of electrosurgery (high voltage low amperage)

A

Electrofulguration and Electrodessication

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6
Q

What is the difference between Electrofulguration and Electrodessication.

A

Electrofulguration tip does not touch the tissue and there is an arc, carbon eschar prevents deep destruction.

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7
Q

Name two biterminal forms of Electrosurgery

A

Electrocoagulation and Electrosection

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8
Q

What is the difference between Electrocoagulation and Electrosection

A

Both are low voltage high amperage, but Electosection is undampened current

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9
Q

what type a electrosurgery requires an indiferent electrode.

A

Electrosection

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10
Q

What temperature does melanocytic necrosis occur at?

A

-5 degree Centigrade

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11
Q

what is the pH of Lidocaine?

A

2.5 - 4.0

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12
Q

What are the three outcomes of adding bicarbonate to Lidocaine?

A

Raises pH with lowers pain
Lowers pKa which causes faster onset.
lowers protein binding which reduces duration.

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13
Q

At what blood pressure should you consider deferring surgery.

A

> 200/100

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14
Q

Which has a higher rate of infection suturing or secondary intention healing on the lower extremity?

A

secondary intention healing

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15
Q

What two things to do to prevent air embolism in open parietal emissary veins.

A

Keep patient prone

Use bone wax over openings.

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16
Q

What are the margins for excising a melanoma?

A

In situ .5-1cm
<1mm 1cm
1 to 2mm 1-2 cm
>2 mm 2cm

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17
Q

what are two advantages of a split thickness skin graft over a full thickness graph?

A
  1. can cover larger areas.

2. can survive better on poorly vascularized wound beds.

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18
Q

Name two devices to harvest split thickness graphs?

A

A Weck blade or a dermatome.

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19
Q

What % of skin surgeries get wound infections?

A

< 3%

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20
Q

Are wound cultures recommended for post op infections?

A

Yes

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21
Q

what are the for stages of healing in an acute injury such as Mohs surgery.

A
  1. hemostasis - fibrin and platelet plug form
  2. inflammation
  3. proliferation
  4. remodeling
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22
Q

During the inflammatory phase of wound healing what cell phagocytose pathogens, degrade debris, stimulate formation of granulation tissue and stimulate angiogenesis.

A

Macrophages

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23
Q

What excision surgical margins with a regular SCC gives a 95% clearance rate.

A

4mm margins

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24
Q

what excision margins with a high risk SCC > 2cm gives a 95% clearance rate.

A

6mm margins

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25
Q

What are the NCCN guidelines for non-Mohs excision of a SCC regarding margins.

A

4 to 6 mm margins.

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26
Q

What is the recurrence rate for SCC with Mohs at 5 years.

A

10%

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27
Q

what are margins for excisional bx of a suspected melanoma.

A

1-3 mm

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28
Q

Which is better for coagulation for a melanoma bx Aluminum Chloride or Monsels?

A

Aluminum Chloride

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29
Q

What is the INR therapeutic range?

A

2-3

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30
Q

Name two drugs that can lead to increased risk of dehiscence.

A

Sirolimus and Prednisone.

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31
Q

What is the tensile strength of collagen at one wk and three weeks?

A

3% and 20% at 1year it is 80%

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32
Q

What is the amount of lidocaine per Kilogram without epi. and with epi

A

4.5 mg/Kg without 7mg/Kg with epi

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33
Q

If you wipe Iodine with what it will remove it?

A

Alcohol - Use alcohol first.

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34
Q

Name an antiseptic that is resistant to removal by alcohol.

A

Chlorhexidine gluconate

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35
Q

Does Chlorhexidine gluconate bind to the stratum corneum?

A

yes

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36
Q

Is Chlorhexidine gluconate good for both viruses and bacteria.

A

Yes. Low concentrations are bacteriostatic, high are cidal.

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37
Q

Where is lidocaine removed from body?

A

Metabolized in the liver mitochondria by P450.

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38
Q

is lidocaine an amide or an ester?

A

amide

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39
Q

When might you give pre-op antibiotics?

A

skin infections and mucosal surgery.

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40
Q

What are the two antibiotics of choice and dosage for preop if there is a skin infection.

A

Cephalexin or dicloxacillin 2gms

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41
Q

For mucosal surgery what is the best pre op antibiotic.

A

Ampicillin. 2grms

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42
Q

What are two alternatives if you need pre op antibiotics and have a PCN allergic patient?

A

Clindamycin 600mg or

Azithromycin 500mg

43
Q

What topical medicine can give someone methemoglobinemia?

A

EMLA cream

44
Q

What type of patient is more likely to get methemoglobinemia from EMLA cream?

A

Baby less than a year old.
Someone with G6 PD deficiency
Someone taking dapsone or phenobarbital

45
Q

What are the two drugs in EMLA cream

A

Lidocaine and Prilocaine both 2.5%

46
Q

How does EMLA cream cause methemoglobinemia?

A

It is the prilocaine. It oxidizes Fe from Ferrous to Ferric state.

47
Q

What is imbibition.

A

The first stage in the healing process of a graft. Lasts for 24 to 48 hours. I thin film of fibrin forms between graft and bed.

48
Q

what is the least reactive non absorbable suture

A

prolene

49
Q

what suture is best for running subcuticular closures due to low coefficient of friction and low reactivity

A

prolene

50
Q

What is the problem with using betadine

A

must be dry to be effective and it is inactivated by blood.

51
Q

what areas should chlorhexidine not be used

A

Hibiclens around eyes and ears. can cause keratitis and ototoxicity

52
Q

what pre op cleanser has the highest rate of allergic contact dermatitis

A

Iodine Iodophor

53
Q

Staphylococcal toxic shock syndrome occurs when in skin surgery

A

when there has been nasal packing or nasal surgery cultures are usually neg caused by a superantigen

54
Q

how often are patients incorrect in identifying their surgery site.

A

25%

55
Q

Maximum effect for hemostasis from epi in lidocaine is how many minutes

A

25minutes

56
Q

Is aluminum chloride flammable

A

yes

57
Q

what makes lidocaine less painful on injection warming or cooling?

A

Warming

58
Q

what four things happen when you mix bicarbonate with lidocaine

A
  1. decrease injection pain
  2. increase time of onset
  3. shorten shelf life
  4. shorten duration of action
59
Q

what is the ratio of 8.4% bicarb to Lidocaine with epi

A

1ml:10ml

60
Q

What is the pH of plain Lidocaine

A

6 (it is less acidic that Lido with epi)

61
Q

What is the pH of Lidocaine with epi

A

4.0 +- .5

62
Q

at what blood pressure should you not do surgery and when do you send them to the ER rather than their primary care doctor.

A

> 200/110 If they have symptoms such as nausea, vomiting, headache, dyspnea, chest pain etc… send to ER otherwise schedule with primary care doc.

63
Q

What is the first thing you should do if the blood pressure show malignant hypertension.

A

Check for proper size of cuff and recheck in contralateral arm.

64
Q

What is the definition of malignant hypertension

A

Systolic >180 or

Diastolic >120

65
Q

where do you do a nerve block for the deep peroneal nerve

A

Lateral to the Extensor hallucis longus tendon

66
Q

where do you do a nerve block for the sole of the foot.

A

you inject the tibial nerve the medial malleolus and the achilles tendon.

67
Q

where do you inject to numb the little toe?

A

the sural nerve inject between the lateral malleolus and the achilles tendon.

68
Q

where do you inject for the saphenous nerve (medial foot) and the superficial peroneal nerve (top of foot)

A

superficial injections at the foot ankle junction crossing from malleolus k

69
Q

What is the drug of choice for pregnant women

A

Lidocaine without epi

70
Q

what two endocrine medical conditions should you not give lidocaine mixed with epinephrine?

A

Pheochromocytoma

Hyperthyroidism both conditions may have a greater epinephrine sensitivity

71
Q

What pregnancy class is lidocaine with epi.

A 
with epi class C 
Lidocaine by itself class B
72
Q

If lidocaine with epi is normally a 1:200,000 what can it be diluted to in kids?

A

1:400,000

73
Q

gold handles on needle drivers usually indicate what?

A

tungsten carbide inserts.

74
Q

what should a needle driver be able to grip without slippage if it is working properly.

A

A hair on the back of your hand.

75
Q

what margins should be used with a regular excision (non Mohs)of a well defined BCC?

A

4mm

76
Q

What is the mechanism of local anesthetics.

A

anesthetics are Cations (+ charged ions) thatPrevents depolarization by blocking influx of sodium into cells

77
Q

why are inflammatory sites more difficult to numb up?

A

Inflammatory response reduces pH which makes the anesthetic in a more non-ionic form with less absorption. High pH makes the aesthetic more lipophilic and better absorbed.

78
Q

what determines the the onset and duration of action of an anesthetic

A

(the amine group) hydrophilic

79
Q

where does the amine group bind?

A

nerve cell sodium channel pores

80
Q

what determines the potency of an anesthetic?

A

the aromatic ring which is lipophilic and determines how much diffuses through the cell membrane.

81
Q

Why are ester anesthetics unstable in solution?

A

they are hydrolyzed in plasma by pseudocholinesterase

82
Q

How are amide anesthetics metabolized

A

in the liver by enzymatic degradation using cytochrome P450

83
Q

1% of lidocaine contains how many milligrams of lidocaine per mL

A

10mg

84
Q

What is the maximum dose recommended of lidocaine in dermatologic procedures.

A

500mg or 50ml (1% Lidocaine)

85
Q

A tacking stitch is also known as what and what does it tack to?

A

A suspension stitch. Tacks to periosteum or perichondrium

86
Q

Potency in an injectable anesthetic is directly proportional to what?

A

lipid solubility

87
Q

what affects the speed of onset in an anesthetic?

A

pKa is inversely proportional to speed of onset.
pKa ideal is 50% non ionic 50% ionic, non ionic penetrates better so the higer pKa the more ionic and slower onset of action.

88
Q

what effects duration of an anesthetic?

A

Protein binding capacity is directly proportional to duration.

89
Q

If you apply what over surgical markings it will tend to preserve the marking when wiped with hibiclens or alcohol.

A

Povidone Iodine

90
Q

At what level should a biopsy be taken for infiltrative malignancies.

A

Down into the reticular dermis.

91
Q

which has greater diagnostic accuracy in bcc shave or punch.

A

neither both have the same as long as biopsy depth is appropriate. If the tumor appears invasive then reticular dermis should be included.

92
Q

what does the american heart association consider skin surgery as what risk and what are there recommendations. Low, Intermediate or High

A

low risk, no recommendations for low risk procedures.

93
Q

an SCC with cranial bone involvement has a positive needle bx of a node for SCC. What is the next step?

A

PET-CT scan

94
Q

What lesion on the lip of a woman that looks like a sclerosing BCC may be difficult to diagnose with a superficial biopsy.

A

It is hard to tell a desmoplastic trichoepithelioma which is superficial from a Microcystic adnexal carcinoma which goes deep.

95
Q

What is the average adequate freeze thaw time for AKs, Seb Kers, solar lentigo etc.

A

5-7 seconds

96
Q

What are major risk factors for wound dehiscence

A 
smoking
BMI >35
Diabetes
>65
Infection
Extended duration of surgery
Emergency surgery
peri-operative hypothermia
97
Q

what is the longest acting injectable anesthetic

A

Liposomal bupivacaine (Exparel) 72 hours

98
Q

how much epinephrine is in Liposomal bupivacaine

A

none

99
Q

What patients should not get injected with Liposomal bupivacaine

A

cardiac patients

100
Q

What should be done before injecting Liposomal bupivacaine

A

Inject lidocaine 20 minutes before.

101
Q

maximum vasoconstriction occurs in how many minutes after injection of lidocaine and in how many minutes do you have optium visualization during the skin surgery.

A

10 minutes

25 minutes

102
Q

excising a high risk scc what margin gives 95% clearance

A

6mm

103
Q

In ester anesthetics name a preservative that can cause allergic reactions.

A

sodium metabisulfite (sometimes methylparaben)

Derm Surg questions (26 decks)

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