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Physical Exam 2 Didactic Midterm > Wound Care & Suturing > Flashcards

Wound Care & Suturing Flashcards

1
Q

list stable vs unstable knots

A

Stable - square, surgeons

unstable - simple, granny

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2
Q

the ideal surgical knot should???

A
  1. minimize contact b/w suture & tissue - DEC inflammation and scar formation
  2. _ensure stable configuratio_n to avoid suture disruption which may cause dehiscence (wound rupture along surgical incision)
  3. ensure proper amount of tension -

too much = strangulation or weakened suture material

too little = improper wound healing

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3
Q

indications for one and two handed surgical knot tying

A

repair incisions in deeper structures

multi-layer incisions

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4
Q

list 4 phaes of wound healing

A
  1. hemostasis
  2. inflammation
  3. proliferation
  4. remodeling

HIP R

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5
Q

describe hemostasis

A

step 1

immediately after wounding

  1. platelet plug forms & blood vessels vasoconstrict
  2. thrombus develops to seal the wound
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6
Q

describe inflammation

A

step 2

occurs in the first 2-3 days after injury

WBC remove necrotic tissue and control infection

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7
Q

describe proliferation

A

step 3

begins on the 2nd or 3rd day after injury & lasts for 2-4 weeks

  1. Fibroblasts proliferate –> produce structural proteins (glycosaminoglycans, collagen & elastin)
  2. new capillaries form and epithelial cells migrate across the top of the wound- known as granulation tissue
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8
Q

describe remodeling

A

step 4

  1. new capillaries atrophy and c_ollagen changes from type III to type I_ to give the best tensile strength
  2. myofibroblasts cause scar contracture - scar reinforcement
  3. uniaxial forces acting on the wound shape the remodeling process a
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9
Q

what are the 4 phases of wound healing

A

Hemostasis (immediately after wounding)

  1. platelet plug forms and blood vessels vasoconstrict
  2. thrombus develops to seal the wound

Inflammation (2-3 days after injury)

WBCs remove necrotic tissue and control infection

Proliferation (begins on the 2nd or 3rd day after injury & lasts for 2-4 weeks)

  1. f_ibroblasts proliferate_ into the wound, and produce structural proteins such as glycosaminoglycans, collagen and elastin
  2. Angiogenesis = new capillaries form and epithelial cells migrate across the top of the wound- known as granulation tissue

Remodeling

  1. new capillaries atrophy and collagen changes from type III -> type I and is rearranged to give the best tensile strength
  2. myofibroblasts cause scar contracture.
  3. uniaxial forces acting on the wound shape the remodeling process
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10
Q

describe primary clouse

A

•Best utilized within 6-12 hours

wound edges are neatly approximated

  • rapid return to function
  • good cosmetic outcome (cosmesis)

NO: infection, severely contaminated

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11
Q

when would primary closure be CI

A

infected, severely contaminated

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12
Q

Describe Delayed Primary Closure

A

close after 48-96 hours

used in situations where early primary closure is inappropriate

  • infected
  • severely contaminated)

allows for a period of secondary healing to occur before the wound is closed

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13
Q

define primary vs delayed closure

indications?

timeframe?

A

Primary closure (6-12 hours)

  • wound edges are neatly approximated
  • rapid return to function
  • good cosmetic outcome (cosmesis)

NO: infected, severely contaminated

Delayed/ Secondary closure (48-96hrs)

  • used in situations where early primary closure is inappropriate, i.e. infected, severely contaminated
  • allows for a period of secondary healing to occur before the wound is closed
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14
Q

indications for delayed primary closure

A

infection

severe contamination

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15
Q

what are the suture removal guidelines

time (days)?

A

neck down - 7-10 days

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16
Q

define the vertical mattress technique

A

to evert skin edges

used where wound edges tend to invert (i.e. posterior neck) or wounds on concave surfaces

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17
Q

define horizontal mattress

A
  • everting technique that spreads tension along wound edge; commonly used to pull wound edges together over a distance
  • good for vascular tissue like scalp, thin skin finger and toe web spaces and eyelid
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18
Q

name indications / tissues where you would use horizontal mattress

A

vascular tissue -

  1. scalp
  2. thin skin finger and toe web spaces
  3. eyelid

can serve as an initial suture to hold skin flaps

effective in _holding fragile skin togethe_r (i.e. elderly patient on chronic steroid therapy

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19
Q

indications / tissues for vertical mattress

A

posterior neck) or wounds on concave surfaces

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20
Q

define Frankenstein marks”.

what suture technique are they assoc w/?

A

Vertical Mattress

Natural process wound inflammation and scar retraction will pull loops of suture that lie on the skin surface downward

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21
Q

closure technique for strength and distribution??

A

vertical mattress

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22
Q

“fa, far, near, near” is what technique

A

vertical mattress

23
Q

name some alternatives to sutures

A

staples

skin adhesives

steri-strips

24
Q

what wound should staples be used?

where should we avoid use?

A

used in linear lacerations that have straight, sharp edges which are well aligned

good for scalp

AVOID

cosmetic areas ->

  • hand
  • face
  • legs
  • neck;

if patient will be needing CT or MRI -> cause artifact or may be avulsed by magnetic fields

25
Q

what areas can we use Skin adhesives?

contraindications?

A

face, extremities and torso -> but should be used with subcutaneous sutures in high tension area

•splinting may be required

contraindications:

  • stellate lacerations
  • bite, puncture or infected wound
  • mucosal surfaces
  • Perineum
  • over joints
26
Q

what is the ingredient in skin adhesive

A

Dermabond (2-octylcyanoacrylate)

27
Q

T/F: skin adhesives

  1. use topical anesthetic such as lidocaine
  2. sets in 2.5 minutes, use bacitracin or Vaseline around
A

F - no need for topical anesthetic

T

28
Q

indications for steri-strips

areas to avoid?

A

used for superficial, linear straight clean edges

•benzoin tincture helps provide additional adhesion

AVOID

over joints

areas prone to getting wet

29
Q

T/F steri strips

no damage to nerves, vessels, tendons

can be used as reinforcement over sutures

A

true

30
Q

when using steri-strips what helps provide additional adhesion?

A

benzoin tincture helps provide additional adhesion

31
Q

contraindications to skin adhesives

A
  • stellate lacerations
  • bite, puncture or infected wound
  • mucosal surfaces
  • Perineum
  • over joints
32
Q

when using skin adhesive in high tension areas you should …?

A

use in conjunction w/ subcutaneous sutures and consider splinting

33
Q

describe the difference b/w

1% lidocaine

2% lidocaine

A

1% lidocaine - blocks pain stimuli (pressure & touch remain in tact)

2% lidocaine - blocks ALL timuli

34
Q

lidocaine:

max dose?

how much fluid will an average finger take?

A

maximum dose 4mg/kg

an average finger will take no more than 5cc of total fluid

35
Q

name examples of topical anesthesia

A

TAC-0.5% tetracaine, 1:2,000 epinephrine, 11.8% cocaine

LET- 4% lidocaine, 1:2,000 epinephrine, 0.5% tetracaine

EMLA- eutectic mixture of local anesthetics 2.5% lidocaine and 2.5% prilocaine

36
Q

topical anesthesia is used mostly in..?

A

pediatrics

37
Q

uses of:

TAC

LET

EMLA

A

TAC - face or scalp – as effective as lidocaine

LET - most commonly used, safe on face or scalp

EMLA - approved only for use on intact non-mucosal skin (slower onset than LET)

38
Q

Rare severe toxicity -> seizures, sudden cardiac death

seen w/ what type of anesthesia

A

topical TAC

39
Q

complciatiosn of EMLA

A

Contact dermatitis

Methhemoglobinemia

40
Q

onset time of

TAC

LET

A

TAC - 10-30mins

LET - 20-30mins

41
Q

name types of local anesthesia

A

lidocaine

epi

42
Q

Etiology of epi in local anesthesia

A

potent vasoconstrictive properties-> aids in hemostasis

when mixed with local anesthetics :

  • decreases clearance time –>
  • increasing duration of action
43
Q

avoid Epi in..?

A

digits

Penis

ear

nose

D PEN

44
Q

describe local infiltration

A

injecting a small skin wheal near the edge of the wound or directly into the wound with the smallest gague needle available

then advancing slowly ensuring that each increment of tissue is anesthetized

45
Q

describe tetanus prone wounds

A

Open wounds over 6 hours

> 1cm deep

•stellate lacerations

•soiled with feces, saliva, gunshot

puncture, burn, frostbite

46
Q

indications for tetanus booster

A

>10 yrs since last vaccine

tetanus prone wound & >5 yrs since last vaccine

unconcious patient

47
Q

compare and contrast Dtap vs Tdap

age

indications?

A

Dtap- 6wks - 6 yrs, children who cannot have pertussis vaccine

Tdap- 11yrs or older

48
Q

name solutions used for wound cleaning and when they are apprioproate

saline

idodine

hibicens

peroxide

alcohol

A

•Saline- for high pressure irrigation

•Iodine- anti-septic, best for cleaning skin around wound, can damage cells

•Hibiclens- anti-septic, good for cleaning wounds

  • Peroxide- anti-septic, not very good for cleaning wounds, best for removing blood from clothing
  • Alcohol- anti-septic but burns, good for intact skin cleaning
49
Q

names 2 categories of anesthehia and how they work

A

Two categories which both work by reversibly blocking Na+ gated channels, both are weak bases with lipophilic properties

Amides & esters

amides - Less likely to cause allergic response – less antigenicity

50
Q

define Langer’s Lines and their significance

A
  • Also known as cleavage lines
  • Correspond to natural orientation of collagen fibers in the dermis
  • Generally parallel to underlying muscle fibers
  • Important for improved cosmetic outcomes
51
Q

T/F

The bigger the number, the smaller the size of the sutur

A

true

52
Q

name 3 types of sutures and when they are used

monofil

dermal and fascial

mucosal & scrotal

A

Non-absorbable monofilaments

nylon (Ethilon, Dermalon

polypropylene (Prolene)

polybutester

Absorbable sutures for dermal and fascial closure:

polyglycolic acid, polyglactin 910 (Vicryl

polyioxanone (PDS)

polyglyconate

Absorbable sutures for mucosal and scrotal closure:

chromic gut, polyglactin

910 (Vicryl)

53
Q

Do not tie too tightly or too loosely (‘approximate, don’t strangulate’)

what is the exception to this rule ??

A

deep knots MUST be tight

Physical Exam 2 Didactic Midterm (4 decks)

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