Surg Block 2 (No Foot Notes) Flashcards
By definition, sutures are a ?
How are these categorized?
Foreign body
Material
Configuration
Strength
Absorbability Degradation
What type of suture fibers cause a more intense inflammatory reaction?
How are suture strengths annotated?
Natural>synthetic
#-0 Larger number, smaller diameter
What does suture configuration mean?
What type of configuration has a higher risk of infection?
Single or multiple filaments
Braided
What type of filament requires 5 knots to hold skin together but is not as efficient as ? which requires 3 knots?
What type of knot must be used?
Mono- 5
Multi- 3
Knot
What type of needle is preferred for suturing skin?
What type of needle is used for delicate tissues inside the body such as bowel or vessels?
Cutting
Tapered/round
What type of suture material already has the needle and suture pre-attached?
What type of material has needles at both ends of the suture material?
What are the 4 categories of suture types
Swaged
Double armed
Anastomose vessel/bowel
Absorbable
Non-absorbable
Braided
Monofilament
What are the 3 types of absorbable suture?
What are the 3 types of non-absorbable sutures?
Gut- monofilament
Monocryl- monofilament
Vicryl- multifilament
Ethilon- monofilament
Prolene- monofilament
Silk- multifilament
What is a pro and con of braided suture material
What is a pro and con of monofilament suture material?
Hold knot better d/t pliability
May harbor bacteria in braids
Harder to tie/hold knots
Less wound infections
What is the name of the instrument used for suturing and what part of the finger is used for control?
How much of the suture is loaded?
Needle driver, first joint
50-75% past the tip, perpendicular to driver
What is the name of suture forceps used outside of the body?
What is the name of the forceps used inside of the body?
Both are held similarly to a ?
Adsons
Debakeys
Pencil
Define Extrinisic tension
Tension is inversely proportional to ?
Force that pulls wounds apart
Suture spacing, more bites= less tension
Where are basic laceration sutures started?
Upon completion of the bite, tissue should have ? effect on the edges?
1cm from edge x 2 drives
Evert
4 ‘Do’s’ of suturing technique
What are 6 ‘don’ts’ of suturing
Load needle 50-75% from tip
Insert 90* 1cm from edge
Avoid dulling needle tip, leave tail
Ensure edge eversion
Load needle too far forward Push needle through skin Crush suture materials w/ driver Grab needle tip to pull suture through Pull needle all the way through Let wound edges invert
When are simple interrupted sutures used
How long are these sutures left in place?
External closures
Start in middle, divide wound in half for each placement
7-10days
5 days if on face
When are horizontal mattress sutures used and for how long?
When are vertical mattress sutures used?
Larger lacerations
Leave x 7-10 days
Laceration that poorly evert
When is the Running Suture used
Why is this method preferred?
What is the name of the last knot in this technique and why is it used?
Completed end to end
Tied off at distal end
Used for subcuticular/buried closure
More cosmetic
Holds skin closed
Aberdeen (fishermen) knot- buries entire closure
When are subcuticular sutures used
How are these closed?
Deeper tissues to prevent hematoma/seroma formation
Absorbable suture
Why is caution used when excising limited lipomas?
Define Epidermal Inclusion Cysts and why these ca be so resistant
Usually larger than appear w/ possible vasculature
Sebaceous cyst, hard lump w/ pore
Recur if wall is not removed
Define Pilar Cyst
When are 10, 15 or 11 blades used
EIC on scalp
10- large incisions by cutting w/ hump of blade
15- smaller incisions
11- punctures or cutting sutures for removal, not for long incisions
Wounds should be closed in ? direction across extensor surfaces except for ?
How are dog ears avoided?
Longitudinally
Flexor surface of joint- close transversely
Excise as ellipse four times longer than width
What is the usual medication ratio used for site anesthetization?
Why are these ones selected?
1 : 1 Lidocaine/Marcaine
Lidocaine- faster onset
Marcine- lasts longer
What are the three benefits of using staples for closure?
What is the down side to this closure method?
Very high tensile strength
Quickly placed
Infection resistant
More permanent scar is left
What tool is used to lift sutures off the skin prior to removal?
Why are cover sponges not used for wet/dry dressing changes?
Adsons or hemostat
Microfilaments can act as foreign body
When is silver nitrate used in would closing?
What effect does this cause?
Minor bleeds or to knock down granulation tissue
Grey/necrosis tissue should not be closed but will slough off, leaves flat space epithelization
Local anesthetics are normally weak acids between ?
How do most work?
5.5-6
Block Na
Impair propagation of action potential
What types of nerves are more easily blocked by local anesthetics?
Do not place local anesthetics into ? tissue?
Thinner/myelinated
Infected tissue, inc acidity
Local amides are classified into ? and ?
Which one is the MC used local anesthetic in GenSurg and how can this category be identified?
Amides- metabolized by liver
Esters- metabolized by plasma cholinesterase into PABA, allergen
Amides- have ‘i’ before ‘-caine’
What are the advantages and disadvantages of adding Epi to local anesthetics?
These combos need to be avoided in ? PT populations?
They also need to be avoided in ? areas of the body
Adv: Inc duration of action, Dec bleeding/volume needed for anesthesia
Dis: Inc myocardial activity (Tachy, Hypo, Dysrhythmia)
Cardiac dz HTN DM Hyperthyroid
Tissues supplied by end arteries
What are the MC adverse effects of local anesthetic use?
How are these adverse effects Tx
Dermatitis Urticaria Edema Erythema
Steroid Antihistamine Fluid Epi O2
What are the prodromal Sxs of local anesthetic toxicity
What are the Sxs of CV toxicity?
Metallic taste
Circumorla numbness
Light headed
Tinnitus
HTN to HOTN
Tachy/brady arrhythmias
V-fib leading to collapse
What are the Sxs of severe local anesthetic toxicity?
How is toxicity due to anesthetic injections avoided?
Tonic clonic activity
AMS
Avoid intravascular injections
Aspirate prior to injecting
Max doses for Lidocaine w/ or w/out Epi
How much Epi is in 1% or 2% Lidocaine?
What is Lidocaines onset and duration?
W/out Epi: 4mg/kg, max 300mg
W/ Epi: 7mg/kg, max 500mg
1% Lidocaine= 10mg/ml
2% Lidocaine= 20mg/ml
On: 2-5min
Duration: 30-120min
Bupivacaine is not for PTs under ? age?
What is its max dose?
What is the onset?
What is the duration?
<12y/o
2mg/kg, 100mg
5-10min
2-4hrs
How is anesthetic toxicity managed?
D/c anesthetic
Hyperventilate to dec pCO2, Benzos for seizures
CV Sxs:
IV fluids for HOTN
Shock wide arrhythmias, Drugs for narrow arrhythmias
What type of drugs are more likely to induce malignant hyperthermia?
How does this present?
How is it Tx?
Volatile, Succinylcholine
Hypermetabolism causing fever, tetany, HyperK
Cooling blankets, BiCarb, Dantrolene
What is the sequence of loss after administering clinical anesthesia?
When is the use of peripheral nerve blocks preferred?
Sympathetic tone- dilation
Pain/temp
Pressure
Motor
Rib blocks Digital blocks (plantar/palmar aspects)
Central nerve blocks administer ? drugs and are injected into ?
This form of nerve block is used for ? procedures
Anesthetic Narcotic +/-Epie
Subarachnoid space, CSF
Abdominal LE GU Gyn
Central nerve blocks inhibit ? sensations
What is the MC complication?
Sympathetic Sensory Motor
Post-spinal HA- Tx w/ fluids, caffeine, blood patch
Epidural anesthesia is done by injecting drugs into ?
This type of nerve block requires ?
What type of sensation does this inhibit?
Epidural spaces
Continuous infusions
Larger volume of anesthetic
Sensory, not motor
Epidural anesthesia is good for ? type of injuries?
What are the acute complications from central nerve blocks?
Rib Fxs
Neurogenic shock (HOTN) Tx w/ pressors/fluid
What are the complications that can arise from high spinal central nerve blocks?
How does Cauda Equina Syndrome present?
Bradycardia HOTN Arm tingling
Respiratory distress- ventilate, IV Naloxone
Bowel/bladder dysfunction
Motor/sensory change in legs
What part of the spine innervates the diaphragm?
What is the MC later complication to arise from central nerve blocks?
C3-5
Urinary retention
Epidural hematomas arising as a later complication from central nerve blocks are suspected in ? PTs
How does it present?
These PTs will be recommended for ? type of anesthesia
Anti-coagulated
Loss of neuro function below infusion site
Endotracheal
What is conscious sedation used for?
What is usually the combination used for this type of sedation?
Analgesia
Anxiolysis
Benzo or Propofol + Narcotic
Why is conscious sedation preferred?
What are the 3 goals of general anesthesia
PT maintains own airway, responds to stimuli
Antegrade amnesia
Pain control
Amnesia
Muscle relaxation
Since most PTs are NPO prior to general anesthesia, what meds may they take PO?
What is the name of the maneuver when applying cricoid pressure when intubating?
Antacids
Sellick maneuver
What are the PACU goals that need to be met for d/c?
How are retained foreign bodies screened for prior to the PT leaving the OR?
Out of bed x 30min/ambulatory Stable VS ANO Controlled pain/nausea PO intake and voiding
X-ray and wand
What post-op complications can occur within 0-48hrs?
What can occur 48hrs-30 days later?
Resp/Cardio: Failure to maintain ventilation Aspiration Sudden cardiac event HOTN
UTI/Pneumonia
SIRS
MODS
What post-op complication is one of the MC of general anesthesia?
How can this be reduced/prevented in the pre-op setting?
Atelectasis
Cessation 2wks piror
How does pneumonia present in post-op setting
How does it appear on CXR if it’s early/late
How is it Tx
Fever Tachy +cough
Early= infiltrate Late= consolidation
ABX/Pulm toilet
Intubate/ventilate w/ goal of PCO2 35-45 and O2>95%
How is VAP prevented?
How is aspiration pneumonia avoided?
HOB at 30-45*
Daily liberation trials
PUD/DVT prophylaxis
PO hygiene
NPO x 6hrs prior
NG decompression
Cricoid pressure to avoid insufflating stomach
How is aspiration pneumonia managed?
How is pulmonary edema managed?
Bronchoscopy w/ suction
Bronchial hygiene
ABX
Mechanical ventilation
Sit up
Diuretics PRN
ARDS can be AKA ? and resembles ?
How is ARDS different?
How is it Tx?
Non-cardiogenic pulmonary edema
Pulmonary edema
No response to diuretics
Inc PEEP (10-15cm) to inc functional residual capacity
Lower tidal volumes 5-7ml/kg
FiO2 <60%
Prone position
Why are central lines placed?
What are the complications that can occur?
Administer caustic agents (TPN, ABX, Blood)
Monitor hemodynamics
Longer term placement
Ptx
Arterial injury
Tamponade
Infection
Well’s Criteria
Sxs of DVT
No other Dx explains Sxs
Tachy
Immobile
DVT/PE Hx
Hemoptysis
Ca
> 6- high probability
2-6: mod
<2: low
What will be seen on PE of PE
What images are ordered
O2 <95
Hypoxemia/Hypocarbia
CXR Spiral CT
VQ if pregnant/renal failure
Pulm arteriogram- Dx and Thx bu invasive, reqs central line
How are PEs Tx w/ anticoags?
What is used it PTs are c/i to receiving PO anticoagulation?
IV Heparin/SQ LMWH
PO Warfarin x 6mon; goal INR 2-3
PO Xa/Direct inhibitors: Digatraban, Fondaparinux
IVC filter
How can surgically induced ileus be avoided?
How are GI bleeds mitigated?
Pre-op Entereg (Alvimopan)
PPI/H2 blockers
What ABX are most likely to cause C Diff
When is this Dx considered?
How is it Tx?
Clina Cephalosporins Floroquinolones
> 3 loose stools/24hrs
PO Vanc/Metronidazole
What is the first consideration of an oliguric post-op PT
Intra-renal oliguira is considered in PTs that were given ?
How is post-renal oliguria due to BPH Tx
Pre renal dehydration/hypovolemia
IV contrast ABX and diuretics
Alpha blockers
What is the MC complication of bladder catheterization
? procedures can damage peripheral nerves and cause neurological issues
UTI
Hernia repair: ilio-inguinal, skin numbness
Mastectomy: long thoracic nerve, winged scapula
Para/thyroid: recurrent laryngeal, hoarsness
Carotid endarterectomy: hypoglossal nerve, deviated tongue
DIC is initially a ? problem that progresses into ?
How is it Tx
Prothrombotic
Consuption of all coagulation proteins
FFP
Why does HypoCa occur after blood transfusions
How is Transfusion Related Acute Lung Injury Tx
Ca binds to citrate
D/c transfusion, support respiratory care
No diuretics
What is the lethal triad?
How are large hematoma/seromas Tx
Metabolic acidosis
Coagulopathy
Hypothermia
Aspirate/open decompression
How does early/late fascial dehiscence present?
How are surgical site infections Tx
Early: Salmon colored fluid
Late: incisional hernia
Open Irrigate Pack
Do not reclose
Late sign of Compartment Syndrome
How are decubitus ulcers Tx
Loss of function/pulse
Incise/darin
Debride necrotic tissue
How is a fever worked up?
What cultures are ordered?
Wind: atelectasis, pneumonia
Water: UTI
Wound: SSI
BUS: blood urine sputum
What causes parotiditis
What causes epistaxis
What causes ototoxicity
Inadequate PO hygiene
Dehydration
Unhumidified O2
Aminoglycosides
Vanc
What is used for anaphylaxis Tx
What are the top 3 causes of nosocomial infections
Epi Diphenhydramine Steroids
SSI
C Dif
Catheter UTi
Define ICU death spiral
SIRS: two or more of- Temp >101.5, Tachy/Tachy, Leukocytosis
Sepsis w/ SIRS source
Septic shock- end organ failure/MODS
Death
