SOFT TISSUE Flashcards
Cold-related injury (frostbite) medication
because thrombosis may occur up to 16 hours after rewarming.
Recent studies confirm that thrombolytic therapy with the use of intravenous or intra-arterial tissue plasminogen activator (tPA) in patients with frostbite and no contraindication to tPA is safe and can reduce predicted digit amputations considerably.
Risk factors for poor response to tPA include more than 24 hours of cold exposure, warm ischemia times greater than 6 hours, or evidence of multiple freeze–thaw cycles.
The laboratory risk indicator for necrotizing fasciitis (LRINEC) score has a high discriminative ability negative predictive value of 96% when a cutoff of 6 or more is used to diagnose necrotizing soft tissue infection. Components of the LRINEC score include
C-reactive protein, total white blood cell count, hemoglobin, serum sodium, serum creatinine, and serum glucose.
what organism has poorest prognosis of nec fasc
Clostridial infections have a significantly worse mortality than infections caused by other agents.
most often identified as the single most important laboratory predictor associated with poor outcome of nec fasc
hyponatremia
rule of nines
head and neck 9 upper extremity 9 lower extremity 18 anterior thorax 18 posterior thorax 18 genital 1 hand 1
---- peds hand and neck 18! upper extremity 9 lower extremity 14* anterior thorax 18 posterior thorax 18 genital 1 hand 1
Dermatofibrosarcoma protuberans
locally aggressive and are characterized by slow, infiltrative growth.
infrequently diagnosed cutaneous sarcoma of low to intermediate grade.
minimal metastatic potential but tends to recur locally after surgical excision.
Clinically, the tumors appear plaque-like or nodular
commonly on the trunk and proximal extremities.
Diagnosis of DFSP is best achieved through punch biopsy.
Excisional biopsy should be avoided when a diagnosis of DFSP is clinically suspected, because reexcision will be required to obtain wide negative margins.
Other than routine chest x-ray, no preoperative metastatic work-up is indicated.
Lymph node metastasis is rare; therefore, assessment of lymphatic spread, other than physical examination, is not indicated.
When feasible, based on tumor location, most practitioners endorse complete surgical resection with wide, pathologically negative margins as the optimal treatment for primary or recurrent DFSP.
For tumors occurring on the head, face, or other areas where wide local excision is not cosmetically acceptable, Mohs micrographic surgery may be a reasonable alternative. Radiation therapy is typically provided as adjuvant treatment.
Imiquimod
may be an alternative to surgery for patients with primary facial superficial basal cell carcinoma (BCCs), but long-term clearance is not as good as some of the other treatment modalities.
all, well-defined BCCs extend more than 4 mm beyond their apparent clinical margins.
Treatment of basal cell carcinoma other than surgery and efficacy
cryosurgery,
curettage,
radiation therapy,
photodynamic therapy
These techniques are generally used to treat low-risk tumors, although radiation therapy also has an important role in the management of high-risk BCCs.
do not allow histologic confirmation of tumor clearance.
Surgical management of basal cell carcimoma
used to treat both low- and high-risk BCCs and is generally considered to have the lowest overall failure rate in BCC treatment.
Studies using Mohs micrographic surgery sections, which can accurately detect BCC at any part of the surgical margin, suggest that excision of small (<20 mm), well-defined lesions with a 3-mm peripheral surgical margin will clear the tumor in 85% of cases.
A 4–5-mm peripheral margin will increase the peripheral clearance rate to approximately 95%, indicating that approximately 5% of small, well-defined BCCs extend more than 4 mm beyond their apparent clinical margins.
at highest risk for pressure ulcer development.
Trauma and burn patients, especially those with comorbidities including spinal cord injury or diabetes
Patients with low BMIs and low and high weights are at increased risk for pressure ulcers.
Braden score
To objectively assess pressure ulcer risk,
assess sensory perception, skin moisture, activity, mobility, friction and shear, nutritional status
Fat grafting
delivering adipose-derived stem cells to the injured tissue, particularly after radiation therapy.
After mastectomy and axillary dissection, postmastectomy pain syndrome can be treated with autologous fat grafting into the dermo-hypodermal junction of painful scars.
Autologous fat grafting is also used to treat severe vocal cord scarring.
Although publications are largely based on small case studies,
method of restoring glottis closure and correcting dysphonia due to vocal cord injury.
Fat grafting can be used to improve anal tone for fecal incontinence.
clean/contaminated wounds infection risk SSI
6–7% rate of SSI.
Associated factors with SSI
hyperglycemia,
poor tissue oxygenation,
suboptimal antibiotic delivery to tissue.
perioperative hyperglycemia after both cardiac and noncardiac surgery.
Based on these observations, the following strategies are recommended to prevent SSI in obese patients:
tight perioperative glucose control,
optimized tissue oxygen tension through increased perioperative FIO2,
larger doses of prophylactic antibiotics to maximize serum and tissue concentrations,
and use of minimally invasive approaches where possible.
gangion cyst treatment and recurrence
Some studies show that with reassurance and no further therapy, these cysts can involute spontaneously in approximately 50% of cases.
Conversely, simple aspiration has recurrence rates similar to the involution rate of simple observation, that is, around 50%.
Aspiration with steroid injection is no better, with recurrence rates around 50%. A
lthough excision of the cyst is considered the gold standard of treatment, simple excision without special attention to the pedicle has recurrence rates of approximately 40%.
With special attention to the pedicle, namely excision with ligation of the neck, recurrences rates drop to the 5–16% range. However, surgical complications occur in approximately 8% of patients.
slow-growing masses at the tip of the scapula.
Elastofibroma dorsi
Elastofibroma dorsi treatment and natural history
composed of alternating streaks of fatty and fibrous tissue.
These lesions typically occur in older people, with the mean age at diagnosis being 70 years.
Most of these lesions are asymptomatic, and when symptoms occur, they are generally mild, consisting of swelling, a “clunking” sensation when the shoulder is being moved, and mild to moderate pain.
The differential diagnosis includes a variety of benign and malignant soft tissue tumors, with the chief concern being that of a sarcoma.
step. MRI will show the characteristic findings of alternating streaks of fibrous and fatty tissue (figure 1). This will obviate the need for tissue diagnosis; therefore, fine needle aspiration and incisional biopsy are not necessary.
Although a lipoma is in the differential diagnosis, to reassure the patient that the lesion is a lipoma is wrong. Otherwise, the surgeon will believe that the lesion is in the subcutaneous space instead of its correct location, deep to the subscapular fascia. Surgical intervention is required only for symptoms. The operation of choice is simple excision, which is associated with a nearly zero rate of recurrence.
he pathophysiology of inhalation injury is complex and includes
Tdirect thermal injury to the tracheobronchial tree (NOT lung)
subsequent airway obstruction,
CO2 retention,
and ventilation–perfusion (VQ) mismatch.
activation of the inflammatory cascade leads to increased microvascular permeability, progressive pulmonary edema, and decreased pulmonary compliance.
Bronchoconstriction associated with inhalation injury further impairs gas exchange.
Complications of inhalation injury and its treatment with mechanical ventilation include give percent
pneumonia -
Up to 70% of patients develop pneumonia within the first week after burn injury.
spontaneous pneumothorax.
Proposed treatment for inhalation injury includes
A combination of aerosolized unfractionated heparin, N-acetylcysteine, and albuterol improves lung injury score, pulmonary compliance, and survival in patients with inhalation injury.
intravenous steroids and inhalation therapy with nitric oxide, beta-agonists, and anti-inflammatory agents (such as heparin and N- acetylcysteine).
However, studies examining the effects of steroids on inhalation injury failed to demonstrate any improvement in outcome and, in some cases, showed detrimental effects of increased infectious complications.
Inhaled nitric oxide (INO) lessens VQ mismatch and reduces pulmonary hypertension through vasodilatation of ventilated lung areas.
Multiple studies have shown improvement in oxygenation with the use of INO (clinically significant increase in PaO2/FiO2 ratio in two-thirds of patients).
Unfortunately, no improvement in survival has been shown with INO.
High-frequency oscillatory ventilation
effective in the treatment of patients with acute respiratory distress syndrome (ARDS).
improves oxygenation index in burn patients with ARDS.
NOT for burns inhalation injury becuase it does not improve oxygenation and is associated with a higher incidence of severe hypercapnia.
In addition, use of HFOV complicates other therapies, such as frequent suctioning, bronchoscopy, and delivery of nebulizers.
Field rewarming for frostbite injuries
only if there is no further risk of refreezing.
If pursued, the provider commits to a course that involves controlling pain, maintaining a warm water bath at a constant temperature, and protecting tissues from further injury during transport.
Rubbing of affected tissue may cause undesirable mechanical trauma.
Space heaters or fires in the field should not be used, because slow partial rewarming can be detrimental to recovery.
recommended rewarming for frostbite
Rapid rewarming in a 40–42ºC water bath is the recommended management.
Rewarming time required varies from 30 minutes to 1 hour,
the appearance of red/purple color and pliable texture of the involved part signals the end of vasoconstriction and are signs that warming should cease.
At the time of rewarming, the degree of microvascular damage results in either vascular recovery with dissolution of clots or vascular collapse with thrombosis, ischemia, necrosis, and gangrene.
There is no evidence that antiseptic solutions at rewarming affects wound infection rates.
Bowen disease
carcinoma in situ of the skin.
Predisposing factors include sun exposure, chronic immunosuppression (e.g., HIV therapy), and human papilloma virus infection (HPV; e.g., anal neoplasia).
The damage, whether from sun, immunosuppression, or virus, is not local.
Wide local resection is all that is required. The tissue adjacent to the noninvasive lesion is also at high risk of neoplasia. HIV-positive status is not an independent predictor of disease, although HPV infection is.
Men and women are similarly affected.
Radiation can be used to retard the progression of disease in critical areas of the skin, but it is not the preferred therapy for treating most lesions.
Spitz nevi
Spitz - “starburst”
benign melanocytic proliferations that usually present as solitary lesions.
most commonly found on the head, trunk, or extremities in children younger than 10 years.
The nevus shares many clinical and histological features with melanoma, thereby presenting clinical ambiguity that makes the diagnosis and management of the patient difficult.
In young children, the lesions tend to be pink or red and dome shaped.
The initial pattern may be a “starburst” that transitions to a reticular pattern over time.
Spitz nevi can also be seen in adults. In adults, the nevi may be brown or black. The natural history is not fully understood, and patients should be managed on an individual basis, with efforts made to avoid both overly aggressive or suboptimal management strategies.
Although somewhat controversial, the most common recommended therapy is:
surgery, and excision should include a 1–2 mm margin of normal-appearing skin around the Spitz nevus with confirmation of the pathology.
Enzymatic débridement using collagenase
gained popularity
derived from the bacterial strain Clostridium histolyticum.
Collagenase ointment selective, because it cleaves only 1 type of protein, collagen.
applied at least daily,
moist environment
use with silver dressings reduces activity by more than 50%.
Cadexomer iodine inhibits activity by approximately 90%.
Some antiseptic cleansers containing heavy metal ions, acetic acid, or hypochlorite also reduce the biologic activity of collagenase and should be avoided or removed from the wound bed via cleansing with saline before collagenase is applied.
use with a vacuum-type dressing is not recommended.
