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Office Procedures

Surgery 2

Anesthetic MOA small sensory fibers selectively blocked (shorter distance, longer action potl); mem-stabilizing drugs (dec rate of depolarization); block Na influx
Order of loss of nerve fn with anesthetic Loss of pain, temperature, touch, proprioception, and then skeletal muscle tone.
Anesthetic: order of fibers blocked small, slow, unmyelinated first; C-fibers (pain) before A fibers (motor); unprotonated molecule passes into nerve
Esters = Procaine (Novocaine) (dental); Benzocaine (Americaine) (topical); Cocaine; prone to cause “allergic” rxn; metabolized by pseudocolinesterases
Amides = Lidocaine (Xylocaine) (peripheral infiltration); Bupivacaine (Marcaine) (long acting peripheral infiltration); metabolized in liver
Local anesthetic: tox: early neuro sx lightheaded/dizzy, visual disturbance, tinnitus
Local anesthetic: tox: late neuro sx peri-oral numbness, mx twitches/ tremors, seizure
Local anesthetic: tox: cardiac sx Hypotension (vasodilation), cardiac arrhythmia
Use punch biopsy for: all pigmented lesions
Excisional biopsy Fusiform excision. Length to width ratio of 3:1 & angles in the corners should be ≤ 30 degrees
Suture for soft tissue lesions inverted mattress
Most common, benign epithelial skin tumor = Seborrheic keratosis
Seborrheic keratosis: common locations Predilection toward face, trunk, and extremities
Single or multiple, discrete, dry, rough, adherent scaly lesions = actinic keratosis
Actinic keratosis: Tx skin bx / excision; liquid N2; topical 5% 5-FU cream
Skin ca BCCA 90% of all skin ca; SCCA more aggressive
Skin ca: Tx excision w/ > 0.3cm radial margins; Mohs micrographic surgery; radiation therapy
Melanoma Tx punch/excision bx (NOT shave bx); wide local excision with 1-2 cm radial margins; specimen including all subQ tissue down to fascia; refer pt to surg oncologist?
Do not close a wound that is: >24 hrs old
Absorbable suture (Vicryl) utilized where: below the skin, inside mouth, or where suture removal is difficult
Use non-absorbable suture where: in most skin closures
Staples may be used for: scalp, trunk, some extremity wounds
Suture size: 5-0 or 6-0 face, 3-0 or 4-0 on trunk or extremity
Pt w/tetanus-prone wounds (>6 hrs old, contaminated, devitalized) should receive: tetanus toxoid if last booster was >5 yrs before injury; tetanus toxoid plus tetanus Ig if no prior vax
Pts w/ non-tetanus-prone wounds should receive: tetanus toxoid alone if last booster was >10 yrs ago
Dirty wounds (or >8 hrs old) should be: thoroughly debrided and allowed to heal by secondary intention
Puncture wounds should be considered: dirty (stab, bullet)
Defn Abscess: localized collections of pus; fluctuant (soft, fluid-like) or indurated (hard) (if cellulitis)
Defn Boils staph infections of follicular or sebaceous glands
Defn Furuncles acute, single-loculated abscesses; may suppurate & necrose or regress / be reabsorbed (warm, moist compresses may quicken localization of small abscesses)
Defn Carbuncles larger, often multi-loculated abscesses, which usually require I&D
Paronychias: occur at the nail base due to trauma
Felons: abscesses of the pulp of the finger
Animal bites: tx Wounds should be left open initially; broad-spectrum Abx; rabies watch
Pigmented lesions: look for: Asymmetry; Borders (irregular); Color (variegated); Diameter (increasing)
Local anesthetic: topical or intradermal/subcutaneous infiltration at the wound site
Field block: infiltration of local anesthetics circumferentially around the wound; for irregular wounds or in areas w/thin or difficult-to-handle skin
Peripheral nerve block: injection of local anesthetics adjacent to appropriate peripheral nerve (usually digital)
tetanus prophalaxis for a tetanus prone wound, never immunized previously or unknown tetanus toxoid plus tetanus immune globulin at separate site
tetanus prophalaxis for a non-tetanus prone wound, last booster >10 years ago tetanus toxoid alone
infection of hair follicle cuased by obstruction furuncle
infection of the terminal phalanx or pulp of the finger felon
infection involving the subepithelial folds of tissue around the nailbed paronychia
technique for fusiform excision length to width ratio of 3:1 with corner angles at approximately 30 degrees
most common benign epithelial skin tumor seborrheic keratosis
most common type of skin cancer basal cell carcinoma
characteristic appearance of a basal cell carcinoma pearly lesion
treatment for all pigmented lesion punch biopsy or excision biopsy
Created by: Abarnard