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Surg Seminars
Surgery
| Question | Answer |
|---|---|
| 2 basic kinds of suture. | absorbable and nonabsorbable |
| 4 types of absorbable sutures. | plain gut, chromic gut, Dexon, and Vicryl |
| Source of plain and chromic gut sutures. | tough submucosal layer of the hog intestine |
| Plain vs chromic gut sutures (tensile strength) | Plain gut is unmodified & loses tensile strength in 1 to 2 wks; chromic gut is soaked in chromic acid salts, retains its strength for 2 to 3 wks |
| How long tensile strength is maintained in Dexon and Vicryl | 2 to 3 weeks |
| 4 groups of nonabsorbable sutures | silk and cotton, braided synthetics, monofilament synthetics, and wire |
| 3 reasons silk is most commonly used suture material. | Silk is easy to handle, easy to tie, and holds knots well. Silk will stay securely tied if tied with three knots |
| Advantages of braided synthetic sutures over silk. | less reactive than silk; good retention of tensile strength; relatively inert in uninfected tissue |
| Pos & cons of monofilament sutures. | more difficult to handle and tie and hold knots poorly; very inert & do not shelter bac; heal without stitch abscesses; hold their strength well with time |
| Pos & cons of using wire suture. | adapt to tissue more poorly than monofilaments, small open spaces; hard to tie; larger must be twisted (adv in suturing bone); retains its strength well |
| Grading system for suture sizes | Largest = 5; smallest = 10-0 |
| Absorbable vs. nonabsorbable sutures | use absorbable if continued strength not important, or infxn issue favors absorbable; Nonabsorbable used if need minimal tissue rxn, or continued strength beyond 2-3 wks, or suture will be removed |
| 4 surgical needle characteristics | eye, shape, point and cross section, and size |
| Mayo needle | stout, curved, tapered needle, available in several sizes; often for suturing fascia |
| Keith needle | 6 - 7 cm straight cutting needle used on the skin; needle itself is 3-4 times as big as the suture |
| French eye needle | fine curved needle in the 1.5 to 2 cm range, has a spring-like eye |
| Swaged needle | fastened to the end of the suture during manufacture & needs to be no larger than the suture itself; for CV & intestine surg; for and for nylon or polypropylene sutures |
| Taper (atraumatic) | for soft tissues and fascia, the tapered needle, round in cross section is best. |
| Conventional cutting needle | puts a small cut in the direction of pull of the suture; easier to pass through the tissue |
| Reverse cutting needle | have a flat edge in the direction of pull |
| Ground point wire | saber point that has sharp edges, while the body of the needle is round in cross section; sharp enough to penetrate & sew grafts |
| Square knot = | Strongest knot; 80-90% of tensile strength of uninterrupted strand. |
| Four principles of suturing | Approximate-do not strangulate; use smallest size suture necessary to maintain closure; small sutures placed close together = lg sutures placed farther apart; wound tension is best relieved by using subcutaneous absorbable sutures |
| Bite = | amount of tissue taken when placing the suture needle |
| Throw = | Each suture knot consists of a series of throws |
| Skin closure | Sutures, usually of a nonabsorbable material, placed in the skin with the knot tied on the surface |
| Dermal closure | Sutures, usually of an absorbable material, that are placed in the superficial(subcutaneous) fascia and dermis with the knot buried in the wound |
| Subcuticular (pull-out) suture | an excellent cosmetic closure because it eliminates the crosshatching caused by suture marks. This technique is limited to straight lacerations less than 2-3 inches long |
| Why is layer matching important when closing wounds. | Failure to appose layers meticulously can cause improper healing with an unnecessarily large scar |
| Wound edge eversion | sl raised wound edge above plane of normal skin will flatten w/ healing; edges that are not everted will contract into linear pits = noticeable cosmetic defects. |
| Define dead space | These spaces tend fill with fluid and can be potential sites for infection |
| Problems caused by too much wound edge tension | minimize tension in order to preserve capillary blood flow to the wound edge |
| 3 techniques to reduce wound edge tension | Dermal (Deep) Closures; Wound Undermining; More Sutures |
| Pros of wound taping | Pro: less need for anesthesia, ease of application, even distn of tension across wound, no residual suture marks, elim need suture removal. |
| Cons of wound taping | Cons: do not work well near joints, on hair bearing surfaces, wounds under tension, in very young or noncompliant pts, or on wounds that cannot be made free of blood or secretions |
| Describe the correct methods to hold forceps | Pencil grip |
| most important principle of wound care: | copious irrigation and adequate debridement |
| Langers lines | Conn tissue bundles usu follow a predictable course within the dermis; wound closures parallel to these lines remain thin leaving small scars |
| Wound closure: if time after injury is <8 hours: | Primary closure |
| Contaminated wounds or wounds treated after 6 - 8 hrs: | delayed-primary closure or delayed closure |
| Puncture wound: | leave open |
| List five causes of shock | cardiac compressive; cardiogenic; hypovolemic; neurogenic; septic |
| initial tx: cardiac compressive shock: | correction of the mechanical abnormality. |
| initial tx: cardiogenic shock: | cautious fluid administration to increase preload; ACEI, beta blockers |
| initial tx: hypovolemic shock: | lg bore IV access; crystalloid infusion; PRBCs? |
| initial tx: neurogenic shock: | IV fluids; Peripheral vasoconstrictors? |
| initial tx: septic shock: | clear offending infxn (Abx, débride, resect); supportive / resp |
| Indications for PRBCs | hypovolemia + anemia; symptomatic anemia |
| Indications for platelets | Plts <50,000 (bleeding); Plts <15,000 (asymptomatic) |
| Indications for fresh frozen plasma | bleeding & coagulopathy; coumadin reversal |
| Indications for cryoprecipitate | Fibrinogen <100 mg/dL |
| Risks of transfusion | hemolytic rxn; febrile nonhemo rxn (vs WBCs); dz transmission |
| Organisms: skin/scalp | staph epi & staph aureus |
| Organisms: nose/sinus | strep & H flu |
| Organisms: mouth | strep spp & Eikenella |
| Organisms: feet | pseudomonas |
| Organisms: cat bite | Pasteurella |
| Organisms: dog bite | Strep viridans |
| Post-op diarrhea often due to: | C. diff (tx: PO Flagyl) |
| Phases of wound healing | inflam (1-10 d); proliferation (5d – 3 wks); remodeling (3 wks-1 yr) |
| Ways to handle tissue that minimize risk of infection | Sterile technique; Minimize tissue damage; Prophylactic Abx (peak = same time as skin incision); outcomes clinical research to systematically identify problems |
| Infections occurring within 48 hours post-op: | If rapidly spreading: possibly necrotizing fasciitis due to Clostridia or Strep. B |
| Most common post-op infxn | UTI |
| Post-op infxn <POD3 | pneumonia |
| Most common cause of post-op fever | atalectasis |
| Post-op infxn POD3 | UTI |
| Post-op infxn: usu POD5 | Wound infxn |
| Veins for IV: usu first choice | metacarpal veins |
Created by:
Abarnard
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