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Surgery > Surgery: Exam 2 > Flashcards

Surgery: Exam 2 Flashcards

1
Q

How does primary intention heal?

A

By the process of epithelialization

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2
Q

What layers of skin are involved in primary intention?

A

Epidermis and dermis, w/o total penetration of dermis

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3
Q

How do most sx wounds heal?

A

By primary intention

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4
Q

What are used to close wounds which are closing via primary intention?

A

Sutures, staples, or adhesive tape

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5
Q

What are some examples when you would want a wound to heal by primary intention?

A

Well-repaired lacerations; healing after flap sx; sx incisions

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6
Q

What type of wound healing would you want to pack gauze or use a drainage system?

A

Secondary intention

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7
Q

In what type of wound healing is the wound allowed to granulate?

A

Secondary intention

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8
Q

What type of wound heals slower, primary or secondary intention? Why?

A

Secondary intention bc there is drainage from infection

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9
Q

Does secondary intention allow for minimal or broader scarring? Why?

A

Broader bc it is allowed to granulate

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10
Q

What type of wound healing requires daily wound care?

A

Secondary intention=encourages wound debris removal to allow for granulation tissue formation

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11
Q

What are some examples when you would want a wound to heal by secondary intention?

A

Skin tears; foot ulcerations

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12
Q

What are some other names for tertiary intention?

A
  • Delayed primary closure (DPC on OR orders)

- Secondary suture

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13
Q

What is unique about tertiary intention wound healing?

A

The wound is purposely left open

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14
Q

When would a surgeon want a wound to heal by tertiary intention?

A

When a wound is contaminated=it’s able to be cleaned, debrided, and observed (typically 4-5d prior to closure)

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15
Q

What are some examples when you would want a wound to heal by tertiary intention?

A
  • Healing of wounds by tissue grafts

- Wounds that result from incision and drainage of an abscess or other infection

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16
Q

Use tissue GRAFTS instead of tissue substitutes

A

Use tissue GRAFTS instead of tissue substitutes

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17
Q

What WBCs migrate to the wound in the first 24h in a wound healing via primary intention?

A

Neutrophils

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18
Q

What processes/cells are occuring during days 3-7 in a wound healing via primary intention?

A
  • Mitosis
  • Granulation tissue formation
  • Macrophage and fibroblast migration
  • Angiogenesis
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19
Q

What factors/hormones are increased in tissue response to injury? Decreased?

A 
Increased
  -ACTH
  -Cortisol
  -Aldosterone
  -Renin
  -Epi and NE
  -GH
  -Glucagon
Decreased
  -TSH
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20
Q

What occurs in the Early Phase of the metabolic response to injury?

A
  • Decr body cell mass
  • Vasoconstriction=so you don’t bleed out
  • Change in energy source
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21
Q

What occurs in the Second Phase of the metabolic response to injury?

A
  • Water and salt diuresis
  • Incr appetite
  • Regain strength
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22
Q

What occurs in the Third Phase of the metabolic response to injury?

A
  • Normal appetite

- Incr in physical activity, strength, and weight

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23
Q

What occurs in the Fourth Phase of the metabolic response to injury?

A

-FAT GAIN PHASE

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24
Q

What is the “newer view” of how skin/tissue heals (compared to the “traditional” inflammatory, repair, and remodeling stages)?

A
  1. Vascular and inflammatory stage
  2. Re-epithelialization
  3. Granulation tissue formation
  4. Fibroplasia and matrix formation
  5. Wound contraction
  6. Neovascularization
  7. Matrix and collagen remodeling
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25
Q

What is the role of fibronectin?

A
  • Crosslinks w/ fibrin to provide matrix for cell adhesion and migration
  • Early component of ECM
  • Binds collagen and interacts w/ GAGs
  • Chemotactant for MACs, fibroblasts, endothelial, and epidermal cells
  • Promotes phagocytosis
  • Forms a component of the fibronexus
  • Forms scaffolding for collagen deposition
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26
Q

What is wound contraction?

A

Centripetal movement of the edges of a full thickness wound in order to facilitate closure of the defect

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27
Q

Wound is wound healing at its max?

A

~15d after wound creation–>important when removing sutures=removed at day 14 bc that’s when healing is at its max

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28
Q

What makes the fibronexus?

A

Intimate association btwn the membranes of the myofibroblasts, intracellular actin microfilaments, and extracellular fibronectin fibers

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29
Q

What is the most common cause(s) for prolonged wound healing?

A
  • Prolonged inflam phase

- Incr toxins and damaging proteases in wound compete for O2 and nutrients

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30
Q

What is the #1 rule about wounds?

A

Make sure it’s CLEAN!

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31
Q

What are some local factors that affect wound healing?

A

-Vascularity
-Infection
-Pressure-
Hematoma formation
-Sx technique
-Foreign body rxn
-Topical meds
-Dresings

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32
Q

What’s imp regarding sx technique and wound healing?

A

You want to sew, NOT strengulate (suture technique)

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33
Q

Why is hematoma formation bad in wound healing?

A
  • Means there’s excess bleeding=media for bacteria to grow
  • Can incr tension on the incision
  • *Manage your deadspace!**
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34
Q

T or F, you can use ANY suture technique on ANY patient?

A

FALSE! Suture choice matters and differs from pt to pt bc each pt will respond differently to foreign bodies (like sutures)

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35
Q

What causes tissue ischemia in wound healing?

A
  • Foreign bodies
  • Infection
  • Strangulation of tissue (from sutures)
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36
Q

Why is local ischemia BAD news?

A
  • Decreases cell proliferation
  • Decr resistance to infection
  • Decr collagen production
  • *RESPECT BLOOD FLOW**
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37
Q

What are the ideal types of dressings used for wound healing?

A

Dressings that are semi-occlusive to occlusive=optimize humidity and cell migration
It’s really MORE than just a dressing

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38
Q

Deficiency in Vit A does what to wound healing?

A

Slows re-epithelialization, decr collagen synthesis, and ultimately incr infection

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39
Q

What “trace elements” are important for particular enzymes needed for wound healing?

A
  • Zinc=DNA, RNA polymerases…deficiency=impaired immune response, decr protein and collagen synthesis, and interference w/ Vit A transport
  • Copper
  • Iron
  • Manganese
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40
Q

What two classes of drugs are esp important factors that affect wound healing?

A
  • Glucocorticoids=directly inhibit wound healing

- Anticoags=Incr chance of hematoma formation

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41
Q

Catgut is an example of what type of suture?

A

Natural, absorbable suture

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42
Q

Polyglactin (vicryl) is what type of suture?

A

Synthetic, absorbable suture

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43
Q

Polyglycolic acid (dexon) is what type of suture?

A

Synthetic, absorbable suture

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44
Q

Polyglyconate is what type of suture?

A

Synthetic absorbable suture

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45
Q

Silk linen is what type of suture?

A

Natural, NON-absorbable suture

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46
Q

Polyamide (nylon) is what type of suture?

A

Synthetic, NON-absorbable suture

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47
Q

Polyester (dacron) is what type of suture?

A

Synthetic, NON-abosrbable suture

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48
Q

Polypropylene (prolene) is what type of suture?

A

Synthetic, NON-abosrbable suture

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49
Q

What synthetic, non-absorbable suture accommodates swelling?

A

Polyamide or nylon

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50
Q

What synthetic, non-absorbable suture has an antimicrobial component?

A

Polypropylene or prolene

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51
Q

When would you use vicryl sutures?

A

When closing up SQ and deep tissues

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52
Q

After 2 weeks, how strong is the surgical wound compared to normal skin?

A

3-5% of the original strength

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53
Q

After 3 weeks, how strong is the surgical wound compared to normal skin?

A

20% of ultimate strength achieved

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54
Q

After 4 weeks, how strong is the surgical wound compared to normal skin?

A

50% of ultimate strength attained

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55
Q

What are some general uses of absorbable sutures?

A
  • Used in SQ tissues
  • Eliminates dead space
  • Minimizes tension on wound edges
  • May “spit” if placed too superficially
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56
Q

If using Surgical Gut sutures, what is the strength of the wound after 1 week? 2 weeks?

A
  • 60% lost

- 100% lost

57
Q

How are Surgical Gut sutures absorbed?

A

Proteolytic enzymatic degradation

58
Q

How are Polyglycolic acid (Dexon) sutures absorbed?

A

Hydrolysis

59
Q

If using Polyglycolic acid (Dexon) sutures, what is the strength of the wound after 2 week?

A

65% of tensile strength remains

60
Q

What factors are important in deciding on a type of suture?

A
  • Location of wound
  • Static and dynamic tension on the wound
  • Presence of infection
  • Potential for edema
  • Cost of suture material
61
Q

What is the smallest suture?

A

7-0. Podiatric surgeons typically use 4.0-2.0 sutures

62
Q

How long are plantar sutures left in?

A

At least 3 weeks

63
Q

What is important when performing simple interrupted sutures?

A

Making sure you EVERT the skin edges

64
Q

When would you use the horizontal mattress suture technique?

A

In longer wounds or calcaneal/ankle fractures

65
Q

When would you use the vertical mattress suture technique?

A

When a pt has a deep wound; many variations and forms a straight line (far-far, near-near throw)

66
Q

What is the goal of retention sutures?

A

Take tension off skin edges and provide deeper and wider support to the healing incision

67
Q

What type of suture technique:

  • is technically demanding
  • leaves relatively no scar if done correctly
  • has a high rate of dehiscence if done correctly
  • is good foe elective surgeries
A

Subcuticular suturing

68
Q

What are the pro’s to using staples?

A
  • Fast and easy
  • Allow for swelling
  • Easy to evert skin edges
69
Q

What are the con’s to using staples?

A
  • Leave track marks

- Painful to remove

70
Q

What is a keloid scar?

A

Overabundance of scar tissue formation due to collagen deposition that extends BEYOND original incision site

71
Q

What is a hypertrophic scar?

A

Overabundance of scar tissue formation due to collagen deposition that DOES NOT extend beyond original incision site

72
Q

What are the treatments for keloid/hypertrophic scars?

A
  • Cortisone injections

- Scar revision

73
Q

In regards to cortisone injections, what is the preferred drug?

A

Kenalog 40mg=injected directly into scar and away from healthy tissue–>decreases the level of collagenase inhibitors and increases collagen deposition

74
Q

What is important in scar revision?

A

The length of the scar MUST BE 3X the width so you can bring the skin back together

75
Q

In what stage of skin graft healing will you see a fibrin layer between the graft and host?

A

Plasmatic stage

76
Q

In what stage of skin graft healing will you see revascularization of the graft?

A

Inosculation stage

77
Q

In what stage of skin graft healing will you see a pinkish hue?

A

Inosculation stage

78
Q

In what stage of skin graft healing will you see CT reorganize and regulate vascular and lymphatic flow?

A

Re-organization stage

79
Q

What stage occur simultaneously w/ the re-organization stage of skin graft healing?

A

Re-innervation stage (may req 1-2 years to complete)

80
Q

What are some post-op complications of skin grafting?

A
  • Seroma formation (transudative fluid)
  • Hematoma formation (blood pooling)
  • Graft does not incorporate
  • Graft necrosis
81
Q

What is the most common cause for graft failure? Second most common?

A
  • Seroma or hematoma formation

- Infection

82
Q

What are the 6 foot and ankle angiosomes?

A
  • Medial calcaneal artery
  • Lateral plantar artery
  • Medial plantar artery
  • Lateral calcaneal artery
  • Anterior tibial artery
  • Dorsalis pedis
83
Q

What type of skin flap gets its blood supply from the cutaneous dermal-subdermal plexus?

A

Cutaneous flaps

84
Q

What type of skin flap gets its blood supply from a cutaneous artery?

A

Arterial flaps

85
Q

A Limberg flap is used when the defect is of what shape?

A

Rhomboidal shape

86
Q

What is the primary indication of a Z-plasty skin flap?

A

When you want to lengthen an existing structure (i.e., skin on a rigidly contracted hammer toe)

87
Q

In a Z-plasty skin flap, the greater the angle the…

A

Greater the length gained (and vice versa)

88
Q

What is a V-Y plasty used?

A

When you want to lengthen

89
Q

In a V-Y skin plasty, the apex is proximal or distal?

A

Proximal

90
Q

What is the primary source of blood supply to the skin?

A

Fasciocutaneous arteries

91
Q

What arteries provide a blood supply to the skin?

A

Cutaneous, musculocutaneous, and fasciocutaneous arteries

92
Q

What determines the success of a local cutaneous flap?

A

The presence of an artery at the base of the flap

93
Q

Intrinsic muscle flaps of the foot are what type?

A

Type II- dominant vascular pedicle and minor vascular pedicle

94
Q

A dorsalis pedis flap is an example of what type of flap?

A

Fasciocutaneous Flap

95
Q

What is the degree of difficulty of skin flaps/restoration, from simple to complex?

A

Direct closure–>Grafts–>Local flaps–>Distant flaps–>Tissue transfer

96
Q

What causes a neuropraxia?

A

Severe contusion to a nerve

97
Q

With a neuropraxia, what happens to conductivity?

A

Transmission along the nerve is altered by DECREASED conductivity

98
Q

What causes axontmesis?

A

Crushing injury to a nerve–>Wallerian degeneration

99
Q

What is the worse nerve injury and what characterizes it?

A

Neurotmesis–>complete severence of a nerve which leads to irreversible damage (i.e., the nerve will NOT recover, but the pt might)

100
Q

Relative to the site of injury to a nerve, where do you see swelling occur?

A

DISTAL to the injury

101
Q

What are the functions of a Schwann cell?

A
  • Promote nerve repair
  • Proliferation
  • Secretion of trophic factors and cytokines
  • Phagocytose myelin debris
  • Support of regeneration only lasts for 1-2 months
102
Q

In a nerve injury, what cells are first to the site?

A

Neutrophils=phagocytose debris, modulate recruitment, activate other lymphocytes, and apoptose

103
Q

In a nerve injury, what cells appear after ~1 week?

A

Macrophages=remove myelin debris; stay in axon for days to moths and return to circulation or die by apoptosis

104
Q

In a nerve injury, what cells peak around 14-28 days?

A

T lymphocytes=help by supporting cellular and humoral immunity

105
Q

Tapping along a nerve and producing “distal coursing pain” is what?

A

Tinnel’s sign

106
Q

Tapping along a nerve and producing “proximal coursing pain” is what?

A

Valleaux’s sign

107
Q

What is the specific plasma marker for skeletal muscle damage?

A

Skeletal troponin I

108
Q

How to blood vessels respond to injury?

A

Stimulation of smooth muscle cell growth and associated matrix synthesis that thickens the TUNICA INTIMA forming a neointima

109
Q

What are the stages of blood vessel healing?

A
  • Inflammation
  • Fibroblastic
  • Remodeling
  • *Essentially the same as all other tissues
110
Q

What occurs when blood vessels are in a state of hypoxia?

A

Local ischemia–>increase in VEGF which binds to cognate receptor tyrosine kinases–>new blood vessels are created (angiogenesis)

111
Q

What are the signs (“6 P’s”) of vascular injury?

A
  • Paleness
  • Palor
  • Pokliothermia
  • Polar
  • Pulseless
  • Pain
112
Q

What is Buerger’s test?

A

It’s a special maneuver to test vascularity in the LE. It’s the angle at which the leg is raised before it becomes pale…if a pt has infection, redness will NOT go away; if they have vascular problems, redness WILL go away

113
Q

What’s the name of “special maneuver(s)” to test the vascularity of the LE?

A
  • Buerger’s test

- The Brodie-Trendelenberg test

114
Q

How is the Brodie-Trendelenberg test carried out?

A
  • Elevate leg to 90 degrees
  • TQ around high thigh to occlude great saphenous v
  • Have pt stand
  • Evaluate the filling of the veins
115
Q

A difference in ___ mmHg indicates pathology of the immediate PROXIMAL segment

A

> 30 mmHg

116
Q

What is the Gold Standard for diagnosing a DVT?

A

Venogram=direct visualization of the veins

117
Q

What are the major differences btwn an arterial and venous hemorrhage?

A 
Arterial
  -Pulsatile flow
  -Bright red blood
Venous
  -Oozing
  -Red to dark red blood
118
Q

What type of transfusion product is good for massive hemorrhages?

A

Whole blood

119
Q

What does whole blood NOT have in it?

A

No platelets, nor Factors V, VIII, or XI

120
Q

What is significant about Packed RBCs (PRBC)?

A

It gives you oxygen-carrying capacity w/o the added issue of more volume

121
Q

What is the disadvantage to using Packed RBCs?

A

Anticoagulation (no platelets)

122
Q

What is the minimum acceptable platelet level for elective surgery?

A

50,000 cells/microliter (ideally you want >100,000)

123
Q

What is the typical dose for platelets during a transfusion?

A

6-10 units=300-400mls

124
Q

1 unit of PRBCs=how many mls?

A

300 (+/- 50mls)

125
Q

1 unit of whole blood=how many mls?

A

450 (+/- 50mls)

126
Q

What are the advantages to using plasma + soluble detergent?

A
  • Inactivates lipid coated viruses
  • Relatively inert
  • Consistent coagulation factors
127
Q

When is plasma + soluble detergent indicated?

A
  • Coumadin reversal
  • Coagulation factor deficiency
  • Multiple coagulation defects
128
Q

When is cryoprecipitate indicated?

A
  • Factor VIII/XIII deficiency

- Von Willebrand disease

129
Q

What are the most common complications to all blood transfusions?

A
  1. Infection (viral»bacterial)=Hep C&B, HIV, CMV/EBV

2. Transfusion reaction

130
Q

What are the most common complications a/w RBC transfusions

A
  1. Hypocalcemia/citrate toxicity
  2. Hyperkalemia/acidosis
  3. Hypokalemia/alkalosis
  4. Hypothermia
  5. Hemosiderosis
  6. Pulmonary dysfunction
  7. Hemorrhage
131
Q

What is a way to avoid bacterial infections related to blood transfusions?

A

NOT leaving the transfusion pack outside of the refrigerator for >30mins

132
Q

What blood type is the “universal donor”?

A

Type O (40%)

133
Q

What blood type is the “universal recipient”?

A

Type AB

134
Q

What is the most common acute hemolytic transfusion reaction? How is it characterized?

A
  • Category 1

- Characterized by pruritis

135
Q

How is a Category 2 hemolytic transfusion reaction characterized?

A

Agitation, palpitation, HA, increased HR, DOE

136
Q

What are the examples of delayed hemolytic transfusion reactions?

A
  • Graft vs. Host disease (IC pts)
  • Alloimmunization (pregnancy, multiparity, h/o prior transfusions)
  • Anaphylactoid reactions (IgA deficiency)
137
Q

What meds/fluid will be given to a pt experiencing delayed hemolytic transfusion reaction?

A
  • IVF w/ NS/LR
  • Epi (0.05-0.1ml to prevent bronchospasm)
  • Antihistamine
  • Corticosteroids
  • HCO3 prn
138
Q

How would you minimize the risk of non-hemolytic transfusion reactions?

A
  • Slow the rate of transfusion
  • Use minimal volume expanding products
  • Diurese between each unit (i.e., Furosemide)

Surgery (2 decks)

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