Surgery
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| 2 basic kinds of suture. | absorbable and nonabsorbable
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| 4 types of absorbable sutures. | plain gut, chromic gut, Dexon, and Vicryl
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| Source of plain and chromic gut sutures. | tough submucosal layer of the hog intestine
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| 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
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| How long tensile strength is maintained in Dexon and Vicryl | 2 to 3 weeks
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| 4 groups of nonabsorbable sutures | silk and cotton, braided synthetics, monofilament synthetics, and wire
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| 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
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| Advantages of braided synthetic sutures over silk. | less reactive than silk; good retention of tensile strength; relatively inert in uninfected tissue
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| 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
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| 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
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| Grading system for suture sizes | Largest = 5; smallest = 10-0
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| 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
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| 4 surgical needle characteristics | eye, shape, point and cross section, and size
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| Mayo needle | stout, curved, tapered needle, available in several sizes; often for suturing fascia
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| Keith needle | 6 - 7 cm straight cutting needle used on the skin; needle itself is 3-4 times as big as the suture
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| French eye needle | fine curved needle in the 1.5 to 2 cm range, has a spring-like eye
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| 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
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| Taper (atraumatic) | for soft tissues and fascia, the tapered needle, round in cross section is best.
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| Conventional cutting needle | puts a small cut in the direction of pull of the suture; easier to pass through the tissue
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| Reverse cutting needle | have a flat edge in the direction of pull
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| 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
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| Square knot = | Strongest knot; 80-90% of tensile strength of uninterrupted strand.
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| 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
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| Bite = | amount of tissue taken when placing the suture needle
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| Throw = | Each suture knot consists of a series of throws
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| Skin closure | Sutures, usually of a nonabsorbable material, placed in the skin with the knot tied on the surface
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| 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
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| 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
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| Why is layer matching important when closing wounds. | Failure to appose layers meticulously can cause improper healing with an unnecessarily large scar
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| 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.
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| Define dead space | These spaces tend fill with fluid and can be potential sites for infection
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| Problems caused by too much wound edge tension | minimize tension in order to preserve capillary blood flow to the wound edge
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| 3 techniques to reduce wound edge tension | Dermal (Deep) Closures; Wound Undermining; More Sutures
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| 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.
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| 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
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| Describe the correct methods to hold forceps | Pencil grip
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| most important principle of wound care: | copious irrigation and adequate debridement
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| Langers lines | Conn tissue bundles usu follow a predictable course within the dermis; wound closures parallel to these lines remain thin leaving small scars
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| Wound closure: if time after injury is <8 hours: | Primary closure
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| Contaminated wounds or wounds treated after 6 - 8 hrs: | delayed-primary closure or delayed closure
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| Puncture wound: | leave open
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| List five causes of shock | cardiac compressive; cardiogenic; hypovolemic; neurogenic; septic
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| initial tx: cardiac compressive shock: | correction of the mechanical abnormality.
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| initial tx: cardiogenic shock: | cautious fluid administration to increase preload; ACEI, beta blockers
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| initial tx: hypovolemic shock: | lg bore IV access; crystalloid infusion; PRBCs?
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| initial tx: neurogenic shock: | IV fluids; Peripheral vasoconstrictors?
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| initial tx: septic shock: | clear offending infxn (Abx, débride, resect); supportive / resp
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| Indications for PRBCs | hypovolemia + anemia; symptomatic anemia
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| Indications for platelets | Plts <50,000 (bleeding); Plts <15,000 (asymptomatic)
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| Indications for fresh frozen plasma | bleeding & coagulopathy; coumadin reversal
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| Indications for cryoprecipitate | Fibrinogen <100 mg/dL
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| Risks of transfusion | hemolytic rxn; febrile nonhemo rxn (vs WBCs); dz transmission
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| Organisms: skin/scalp | staph epi & staph aureus
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| Organisms: nose/sinus | strep & H flu
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| Organisms: mouth | strep spp & Eikenella
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| Organisms: feet | pseudomonas
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| Organisms: cat bite | Pasteurella
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| Organisms: dog bite | Strep viridans
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| Post-op diarrhea often due to: | C. diff (tx: PO Flagyl)
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| Phases of wound healing | inflam (1-10 d); proliferation (5d – 3 wks); remodeling (3 wks-1 yr)
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| 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
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| Infections occurring within 48 hours post-op: | If rapidly spreading: possibly necrotizing fasciitis due to Clostridia or Strep. B
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| Most common post-op infxn | UTI
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| Post-op infxn <POD3 | pneumonia
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| Most common cause of post-op fever | atalectasis
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| Post-op infxn POD3 | UTI
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| Post-op infxn: usu POD5 | Wound infxn
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| Veins for IV: usu first choice | metacarpal veins
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