Key Terms Flashcards
(132 cards)
1
Q
Where is CSF located?
A
Located in the subarachnoid space.
2
Q
What percent of CSF makes up total brain weight?
A
10-20% of brain weight
3
Q
How much CSF is in the average adult?
A
140 ml
4
Q
What is the production rate of CSF?
A
Production rate: up to 21 ml/hr. On average 50-100 ml produced daily
5
Q
How much CSF is removed in a LP? How fast does it get regenerated?
A
usual amount removed for an LP (4-8mls) is regenerated in less than an hour.
6
Q
Granulating wound bed:
A
healthy red tissue which is deposited during the repair process, presents as pinkish/red colored moist tissue and comprises of newly formed collagen, elastin and capillary networks. The tissue is well vascularized and bleeds easily
7
Q
Epithelializing wound bed:
A
process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy granulation tissue
8
Q
Sloughy wound bed:
A
the presence of devitalized yellowish tissue. Is formed by an accumulation of dead cells. Must not be confused with pus
9
Q
Necrotic wound bed:
A
wound containing dead tissue. It may appear hard dry and black. Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents healing
10
Q
Hyper granulating wound bed:
A
granulation tissue grows above the wound margin. This occurs when the proliferative phase of healing is prolonged usually as a result of bacterial imbalance or irritant forces.
11
Q
What is a Hyper granulating wound bed a characteristic of?
A
a chronic wound
12
Q
How is a wound measured?
A
Assessment and evaluation of the healing rate and treatment modalities are important components of wound care. All wounds require a two-dimensional assessment of the wound opening and a three- dimensional assessment of any cavity or tracking
13
Q
What are the Two-dimensional measurements of a wound and how are they measured?
A
Use a paper tape to measure the length and width in millimeters. The circumference of the wound is traced if the wound edges are not even - often required for chronic wounds. (You may also consider photography)
14
Q
How do we measure a wound depth? (Three -dimensional measures)
A
the wound depth is measured using a dampened cotton tip applicator
15
Q
A wound appears to have Raised wound edges, what would this indicated?
A
where the wound margin is elevated above the surrounding tissue may indicate pressure, trauma or malignant changes
16
Q
A wound appears to have Rolled wound edges, what would this indicated?
A
rolled down towards the wound bed may indicate wound stagnation or wound chronicity
17
Q
A wound appears to have Contraction of the wound edges, what would this indicated?
A
wound edges are coming together, signs of healing
18
Q
What is sensation?
A
increased pain or the absence of sensation should be noted
19
Q
How do healthy wound edges appear?
A
Healthy wound edges present as advancing pink epithelium growing over mature granulated tissue.
20
Q
A wound appears to have dusky wound edges, what would this indicated?
A
dusky edges indicate hypoxia
21
Q
A wound appears to have erythema wound edges, what would this indicated?
A
erythema indicates physiological inflammatory response or cellulitis
22
Q
What is Exudate?
A
Is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the natural healing process. It plays an essential part in the healing process.
23
Q
How does exudate play an essential part in the healing process?
A
- Contains nutrients, energy and growth factors for metabolizing cells
- Contains high quantities of white blood cells
- Cleanses the wound
- Maintains a moist environment
- Promotes epithelialization
24
Q
What happens if there is too much exudate? Too little?
A
Too much exudate leads to maceration and degradation of skin while too little can result in the wound bed drying out.
25
What is a Blood Borne Pathogen?
Pathogenic microorganisms present in blood and other potentially infectious material (OPIM) that are able to cause disease in humans
26
What are the 3 big BBP?
* Hepatitis B virus (HBV, HepB)
* Hepatitis C virus (HCV, HepC)
* Human immunodeficiency virus (HIV)
27
What is the role of a splint?
Splints applied initially (ED, UC) to immobilize joint above and joint below. Splints allow the soft tissue to swell. Can change to cast after swelling reduced.
28
What safety precautions do we have to keep in mind when applying a splint?
Pad all bony prominences well & Do not wrap too tightly
29
When do we use a Long arm splint?
Distal humerus fx, forearm fx, elbow injuries
30
When do we use a Sugartong splint?
Distal radius fx, radial/ulnar fx
31
When do we use a Ulnar Gutter splint?
Metacarpal fx, proximal phalanx fx
32
When do we use a Thumb Spica splint?
Scaphoid fx, 1st metacarpal fx, thumb fx
33
When do we use a Short Leg Posterior splint?
Ankle fx, distal tibia fx
34
What is Compartment Syndrome?
The build up of pressure in soft tissues can cut off blood supply and lead to permanent damage of muscles and nerves.
35
What do we use for cast padding?
Webril, Synthetic material used to provide a cushion between the limb and the fiberglass.
36
How do we implement cast padding?
Generally 2 layers+ are used
Wrap cast padding around the extremity in a distal to proximal fashion; overlap each turn to cover the previous one by 50 percent.
Be careful to avoid wrinkles because they can create pressure points.
Do not wrap too tightly as can cut off circulation
37
What places get extra cast padding?
Extra padding at fibular head, malleoli, patella and olecranon
38
What is Mohs Surgery?
Uses tissue sparing margins, and examines 100% of the margins for cancer cells.
39
What are the indications for Mohs Surgery?
Skin cancers that:
1. Develop on areas where preserving cosmetic appearance and function are important
2. Have recurred after previous treatment or are likely to recur
3. Are located in scar tissue
4. Are large
5. Have edges that are ill-defined
6. Grow rapidly
40
What are the 3 main types of skin cancer?
* Basal Cell Cancer
* Squamous Cell Cancer
* Malignant Melanoma
41
What do you know about Basal Cell Cancer?
It is the most common skin cancer and is frequently found on the nose, face, neck and arms.
42
What do you know about Squamous Cell Cancer?
It is the 2nd most common skin cancer and surgery is usually curative, but 3%-4% may spread distantly.
43
What are the ABCDE's of Melanoma?
ABCD’s: Asymmetry, Border, Color, Diameter (larger than 6 mm)
44
What are the treatments and their efficacies for skin cancer?
* ED&C: 85%
* Topicals/Radiation 75% - 85%
* Simple Excision 88%
* Mohs Surgery >96%
45
What is the epidural space?
The space bounded by:
• the ligamentum flavum posteriorly
• the spinal periosteum laterally
• and the dura anteriorly
46
What goes into epidural anesthesia?
Epidural anesthesia involves placing catheters into the epidural space, allowing continuous infusions administration of local anesthetics.
47
What is the primary site of action of epidural anesthesia?
The primary site of action of epidurally administered local anesthetics is on the spinal nerve roots.
48
What is Xanthochromia?
A yellow, discoloration of the CSF, due to lysis of RBCs. Discoloration begins after RBCs have been in spinal fluid for about two hours, and remains for two to four weeks.
49
What is Xanthochromia indicative of?
A SAH. Xanthochromia is present in more than 90 percent of patients within 12 hours of subarachnoid hemorrhage.
50
What angle do you administer IM anesthesia?
90 degrees
51
What angle do you administer subcutaneous anesthesia?
45 degress
52
What angle do you administer intradermal anesthesia?
15 degrees
53
What are Amide contraindications?
* Heart Blocks, Unstable BP (shock), CHF
| * Allergy to Local Anesthesia
54
T/F:Novocain allergy predicts Lidocaine allergy.
False it does not, Lidocaine is an amide and novocaine an ester
55
What do you use if there is a lidocaine allergy?
* Preservative-free Lidocaine (single use bottles)
| * Diphenhydramine Hydrochloride 1%
56
What are the types of biopsies?
Shave, Punch, & Excisional
57
When do we use a Shave Biopsy?
Most common technique. Used for MOST lesions (SK/AK/MC/WART/BCC/SCC/NEVI)
Should NOT be used for suspected malignant melanoma
58
What are the complications of a shave biopsy?
Bleeding: Use 20% aluminum chloride and/or electrocautery
Scarring: ALWAYS get informed consent – talk about keloids.
Infection: Rare in immunocompetent patients
59
Describe the procedure of a shave biopsy.
1. Clean, but NOT sterile procedure. Clean site with alcohol, inject 1% Lidocaine w/epi, most areas just to point of lesion elevation.
2. Use ½ double-edge razor blade between thumb and forefinger to remove lesion, place in formalin jar.
3. Use Drysol and/or electrocautery for hemostasis.
4. Dress with simple “Band-Aid and petrolatum, NOT Neosporin
NOTE: Be sure to note on pathology form that you request the specimen be read by DERMATOPATHOLOGIST ONLY
60
When do we use a Punch Biopsy?
It is a more complex technique used for lesions that require full-thickness section. (inflammatory dermatoses, hair loss, suspicious pigmented lesions)
Should NOT be used for suspected malignant melanoma
61
Complications
Bleeding: Use direct pressure and/or electrocautery.
Scarring: ALWAYS get informed consent – talk about keloids.
Infection: Rare in immunocompetent patients.
62
Describe a punch biopsy procedure.
1. Clean, but generally NOT sterile procedure. Clean site with alcohol, inject 1% Lidocaine w/epi, most areas just to point of lesion elevation.
2. Insert punch instrument into lesion with twisting motion. GENTLY elevate and divide base with scissors. DO NOT CRUSH! Use pressure/electrocautery for hemostasis
3. Suture with 1 or 2 simple interrupted nylon or Prolene, usually 4-0 or 5-0
4. Dress with “Band-Aid or pressure dressing, if needed
63
When do we us an Excisional Biopsy?
Most complex technique used for suspected melanomas, lipomas, cysts, BCC, SCC. It has the highest insurance fee schedule.
64
Describe the procedure of an Excisional Biopsy.
1. It is a sterile procedure. Mark excisional area (3.5:1 ellipse).
2. Clean site with chlorhexadine, inject 1% Lidocaine w/epi and Drape appropriately.
3. Hold scalpel like a pen, cut down to subcutaneous fat, tag and remove ellipse. Use electrocautery for hemostasis
4. Undermine edges to reduce wound tension, if required. (“Complex repair”)
5. Place subcutaneous absorbable sutures (Vicryl/Maxon) to bring wound edges together, using vertical mattress.
6. Place surface sutures to gently hold wound edges and close the skin (Nylon/Prolene)
7. Dress with bandage and petrolatum
65
What type of suture do you use for a punch biopsy?
Suture with 1 or 2 simple interrupted nylon or Prolene, usually 4-0 or 5-0
66
What type of suture do you use for an excisional biopsy?
Subcutaneous absorbable sutures (Vicryl/Maxon) to bring wound edges together, using vertical mattress.
Surface sutures to gently hold wound edges and close the skin (Nylon/Prolene)
67
Describe to procedure for using anesthesia via infiltration.
1. The smallest gauge needle, usually 27 to 30 should be used to inject all anesthetics. Always draw back prior to injecting.
2. Infiltration should be gentle and slow, into open skin edges. (May distort wound edges).
3. Warm Lidocaine to body temperature. Use Buffered Lidocaine.
4. Cool skin before injection (Ice, Liq Nitrogen, ethyl chloride)
5. Use distraction techniques (Lifting legs, vibrate skin), keep eyes open, talk calmly and explain everything.
6. Allow at least 5-10 minutes to take effect.
68
What causes the pain in anesthesia infiltration?
The pain of injection is caused by insertion of the needle and infiltration of the anesthetic into the skin.
69
Suture size
Want it the same size as your needle
70
What are the Tetanus guidelines?
All wounds should be cleaned. Necrotic tissue and foreign material should be removed.
Tetanus immune globulin (TIG) is recommended for persons with tetanus. TIG can only help remove unbound tetanus toxin. It cannot affect toxin bound to nerve endings.
A single intramuscular dose of 3,000 to 5,000 units is generally recommended for children and adults, with part of the dose infiltrated around the wound if it can be identified.
71
If tetanic spasms are occurring, what do you do?
Give supportive therapy and maintenance of an adequate airway are critical.
72
Describe Venipuncture positioning.
1. The patient should either sit in a chair, lie down or sit up in bed. Hyperextend the patient's arm. The position of the provider is equally important for the success of the venipuncture.
2. Apply the tourniquet 3-4 inches above the selected puncture site. Do not place too tightly or leave on more than 2 minutes.
3. The patient should make a fist without pumping the hand.
4. Select a vein that is readily palpated. Palpate and trace the path of veins with the index finger.
73
How do we tell the difference between arteries and veins?
Arteries pulsate, are most elastic, and have a thick wall. Thrombosed veins lack resilience, feel cord-like, and roll easily.
74
What are complications of Venipuncture?
* Infection of the skin (cellulitis)
* Infection of the vein (phlebitis)
* Thrombosis
* Laceration of the vein
* Hemorrhage or hematoma
* Vasovagal syncope
75
Describe the primary intention mechanisms of wound healing.
most clean surgical wounds and recent traumatic injuries are managed by primary closure. The edges of the wounds are approximated with steri strips, glue, sutures and/or staples. Minimal loss of tissue and scarring results.
76
Describe the delayed primary intention mechanisms of wound healing.
the surgical closure of a wound 3 -5 days after the thorough cleansing or debridement of the wound bed. Used for 1. Traumatic wounds, 2. Contaminated surgical wounds.
77
Describe the secondary intention mechanisms of wound healing.
occurs slowly by granulation, contraction and re-epithelialisation and results in scar formation. Commonly used for 1. Pressure Injuries 2. Leg ulcers 3. Dehisced wounds
78
Describe the skin graft mechanisms of wound healing.
removal of partial or full thickness segment of epidermis and dermis from its blood supply and transplanting it to another site to speed up healing and reduce the risk of infection.
79
Describe the flap mechanisms of wound healing
Flap is a surgical relocation of skin and underlying structures to repair a wound.
80
Where do you administer an LP?
Parallel to the bed usually between L3 and L4, can be between L4 and L5.
81
Once through the SQ tissue the needle is angled _______________.
towards the umbilicus
82
The basic chemical structure of a local anesthetic molecule consists of 3 parts:
Lipophilic group, Intermediate bond & a Hydrophilic group
83
What determines the classification of the anesthetic?
The intermediate bond determines the classification of local anesthetic.
84
What are examples of esters?
Benzocaine, Cocaine, Novocain, Tetracaine
85
Where are esters excreted?
kidney
86
What are examples of amides?
Lidocaine (Xylocaine), Marcaine
87
Where are amides excreted?
liver
88
What is the max dosage of lidocaine?
Max dose of Lido for local anesthesia 3-5 mg/kg
89
How is HBV spread?
Spread through direct contact with infected blood or OPIM; 50-100 times more infectious than HIV
90
How do patients with HBV present?
Infection may be acute or chronic. 5-10 % of infected adults will develop chronic infection. 15-25% develop cirrhosis, liver failure, or liver cancer
Symptoms of acute infection can appear 6 wks - 6 mos after exposure & include:
fever, jaundice, abd pain, loss of appetite, fatigue, n/v, joint pain and dark urine.
91
What his the highest incidence of transmission in a needle stick injury?
HepB from a contaminated source. ~30% of these exposures results in infection
92
Who gets and HBV vaccine?
Given to newborns, 120 million people in U.S. have received at least one dose. Its effective, >95% develop immunity after full series (3 doses given at 0, 1, 6 mos).
Health-care workers or public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids, HBV research lab workers. Performed 1-2 months after dose #3.
93
What are the types and benefits of Absorbable sutures?
Absorbable synthetic Polyglactin/ Polyglycolic: Used in mucosal (mouth/tongue) areas and in multiple layered closures inside the body (dissolving over time).
Chromic and plain gut sutures (Derived from purified pig or cow collagen): Chromic is processed to dissolve over a longer time period.
94
What is a complication of absorbable sutures?
Gut sutures are organic and have a higher incidence of tissue reaction and infection than synthetic fibers
95
How do we go about the I&D process?
1. Cleanse site over abscess with skin prep
2. Drape to create a sterile field
3. Infiltrate local anesthetic, allow 2-3 minutes for anesthetic to take effect
4. Incise widely over abscess with the #11 blade, cutting through the skin (Figure 1) into the abscess cavity. Follow skin fold lines whenever able while making the incision
5. Allow the pus to drain, using the gauzes to soak up drainage and blood. Use culture swab to take culture of abscess contents, swabbing inside the abscess cavity
6. Use the hemostat to gently explore the abscess cavity to break up any loculations within the abscess—make sure to break up any
7. Using the packing strip, pack the abscess cavity
96
What is the use of epinephrine in anesthesia?
Potentiates anesthesia and causes vasoconstriction so less bleeding.
Epinephrine also decreases absorption of the anesthetic agent, which may allow safe injection of more than the usually recommended dosage.
97
Where do we not use epinephrine?
Don’t use it in areas of the body that have a single dependent blood supply (fingers, toes, penis, nose, pinna)
98
Where is epinephrine indicated?
In straight cut with healthy-looking skin edges
On the face, oral mucosa, and scalp, which have excellent blood circulation
99
How long does it take for epinephrine to take effect?
Epinephrine requires 5–7 minutes to take effect.
100
Suture types
Simple interrupted, horizontal mattress, vertical mattress, continuous running, subcuticular. I think we have these figured out already. ☺
101
Describe a Needle stick injury.
Cuts or punctures with contaminated sharp objects (needles, glass, scalpels, etc). Do no recap needles!
102
What are OPIM?
Other potentially infectious material (OPIM) . Cerebrospinal fluid (CSF), synovial fluid, peritoneal fluid, pericardial fluid, pleural fluid, semen, vaginal secretions, breast milk, amniotic fluid, saliva with frank blood (dental procedures), unfixed human tissues or organs (other than intact skin), cell or tissue cultures that may contain BBP agents, blood or tissues from animals infected with BBP agents
103
What are not OPIM?
Tears, feces, urine, saliva, nasal secretions, sputum, sweat, vomit (exceptions: if any of these have frank blood, they are considered OPIM)
104
Surgical scrub principles:
* Rinsing time: Is not to be included in the total scrub time if the timed method is to be used.
* Unsterile objects: Should not be touched once the scrub procedure has begun.
* Entire scrub procedure: Must be repeated if an unsterile object is touched.
* Same scrub procedure: Should be utilized for every scrub, whether it is the first or last one of the day.
105
Hand Drying:
1. Drying towel is lifted up and away from the sterile field without dripping water into that field
2. Bend forward at the waist, fingers and hand are dried thoroughly, then the same part of towel is used to dry remainder of the forearm
3. The other end of the towel is then used to dry the other hand and forearm
106
What is the Needle diameter?
This is the thickness/circumference of the actual needle. This is different from the needle radius which is the amount curvature the needle has
107
What are the different Needle types?
Closed eye, French eye, swaged end (suture material is attached, not threaded); taper, cutting (rips toward the wound margin that may cause suture to pull through), reverse cutting (rips away from the wound margin)
108
Suturing Advantages:
time honored, meticulous closure, tensile strength, low dehiscence
109
Suturing Disadvantages:
requires removal, requires anesthesia, tissue reactivity, high cost
110
Principles of suturing technique:
Don’t want your bites to be too big (won’t keep wound edges together) or too small (too tight and may strangulate the tissue)
The wound edges should have good eversion but not be puckered. Inversion is no bueno!
111
What are the principles of Facial sutures?
want a fairly small suture and needle diameter; preferably 6-0 which has a diameter of 0.07mm - 0.099mm or even smaller! Offers better cosmetic healing.
Most facial sutures are to be removed after 5 days instead of the typical 10-14 day period because the large amount of blood supply to the face allows for faster healing.
112
What is the range of Suture sizes? What is the standard?
Fairly standard is 4-0. 10-0 is extremely small and 1-0 is really big.
113
How long do sutures typically stay in?
10-14 days
114
What suture material gives the best knots? Worst?
best is silk worst is prolene
115
Which suture has the most tissue reactivity?
silk
116
What suture has the best tensile strength?
prolene
117
What are Staples used for?
Another method for wound closure. Often done on scalp and abdominal lacerations or incisions. Provides a very quick way of closing large wounds. Doesn’t provide the best cosmetic effect, though.
118
What is an acute wound?
the result of tissue damaged by trauma. This may be deliberate, as in surgical wounds of procedures, or be due to accidents caused by blunt force, projectiles, heat, electricity, chemicals or friction. An acute wound is by definition expected to progress through the phases of normal healing, resulting in the closure of the wound.
119
What is a chronic wound?
fails to progress or respond to treatment over the normal expected healing time frame (4 weeks) and becomes "stuck" in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection
120
The clinical signs of chronic wounds may include:
* Non viable wound tissue (slough and/or necrosis)
* Lack of healthy granulation tissue (wound tissue may be pale, greyish and avascular)
* No reduction in wound size over time
* Recurrent wound breakdown
121
Describe Serous exudate.
Thin watery Clear, straw colored exudate that can be normal but an increase may be indicative of infection.
122
Describe Haemoserous exudate
Thin watery Clear, pink exudate that is Normal
123
Describe Sanguinous exudate
Thin watery Red exudate characteristic of Trauma to blood vessels
124
Describe Purulent exudate
Thick yellow, grey, green exudate that is characteristic of Infection. Contains pyogenic organisms and other inflammatory cells.
125
What is the only one local anesthetic capable of readily penetrating intact skin?
this is the combination of 5% lidocaine and 5% prilocaine known as EMLA, an acronym for eutectic mixture of local anesthetics.
126
What is Implied consent?
Often used when immediate action is required. (Ex: Someone who came to the ER for Chest pain codes and the crash team performs ACLS)
When anyone, even a minor, comes in after a severe life-threatening injury or malady and may not be awake to provide consent (and parents aren’t there to consent) then it is assumed they want their life to be saved…until they are coherent enough to give consent.
127
What is Informed consent ?
The voluntary consent of the human subject is absolutely essential and any person involved should have legal capacity to give consent.
128
At a minimum, the informed consent should include:
(1) nature of the medical condition, the (2) objectives of the proposed treatment, (3) treatment options, (4) possible outcomes, and the (5) risks involved.
129
The following areas should be avoided when choosing venipuncture site:
Extensive scars from burns and surgery
The upper extremity on the side of a previous mastectomy
Hematoma
Edematous extremities
Cannula/fistula/heparin lock
130
Hand position of function – “coke can sign”
o MCP joint flexion 90 deg
o PIP extension
o Thumb adduction
o Wrist extended 20 deg
131
Eye exam - Corneal abrasion:
fluorescein staining will show linear, vertical abrasions +/- foreign body
132
What are the 4 test tubes in an LP used for?
4 tubes obtained with LP – each gets ~1mL
Tube 1 – hematology – cell count w/ diff
Tube 2 – biochemistry – protein, glucose, electrophoresis Tube 3 – bacteriology – culture, gram stain, & cell count Tube 4 – special studies – VDRL, save in case needed
