Midterm Flashcards
(86 cards)
1
Q
what are the contents of an NCNM suture pack?
A
need holders scissors forceps and pickups hemostats gauze
2
Q
Two types of forceps in NCNM suture pack?
A
Edson Dressing Forceps - 4 3/4” straight
Brown-Adson Tissue Forceps - 4 3/4” straight W TEETH
3
Q
What are needle holders
A
needle holders have serrated or smooth jaws, separating them from hemostats.
Jaws are usually straight and small.
4
Q
What are hemostats?
A
hemostats are typically used for retrieving foreign bodies in a wound, clamping bleeding vessels or clamping a tourniquet
5
Q
What are the typical scalpel sizes and glad configurations and when are each used?
A
All can be used for performing shave biopsies
#10 for large lesions #11 for draining abscesses #15 for small lesions
6
Q
What are the non-absorbable suture materials and when are they used?
A
Barely used, tend to act as a “wick: and draw bacteria into the would.
Nylon - fairly inert, but slippery and difficult to tie
7
Q
Which causes more of a tissue reaction - cotton or silk?
A
cotton
8
Q
What are the absorbable suture materials and when are they used?
A
Gut - first type of absorbable - often called “cat gut” thought really made of sheep intestine
NEWER MATERIALS - synthetic polymers
Vicryl, most widely used.
*Materials have to be phagocytosed, immune reaction can be confused with an infection
9
Q
What are the two types of cutting needles?
A
Conventional cutting - cutting edge acting the inside of the needle curve
Reverse cutting - has the cutting edge acting the outside of the needle curve
There are also
Precision Cosmetic needles what are sharper and of better steel, however, most expensive
10
Q
which suture sizes are best for which body areas?
A
6-0 to 2-0 are the most common sizes for office use
Face/Head: 5-0, 6-0, 7-0
General Body: 3-0, 4-0, 5-0, 6-0
11
Q
common needles sizes for anesthetic injection in minor surgery and applicable locations in the body (4), what’s typical?
A
Aspirate cyst/Ganglion - 18 gauge, 1 1/2”
Drawing up anesthetics: 20 gauge, 1 1/2”; 21, 1”; 22. 1”
Injecting anesthetics - 25 gauge, 5/8” or 1 1/2”
small lesion removal, facial or plastic surgery - 30 gauge, 1/2” or 1”
TYPICAL for minor surgery -
27 gauge, 1”
12
Q
What is sterilization?
A
any process that eliminates (removes) or kills all forms of life, including transmissible agents (such as fungi, bacteria, viruses, spore forms, etc) present on a surface, contained in a fluid, in medication, or in a compound such as biological culture media
13
Q
What are disinfectants
A
destroy microorganisms (but NOT ENDOSPORES or VIRUSES), found on non-living objects by destroying the cell wall of microbes or interfering with the metabolism.
14
Q
What is the concept of antisepsis?
A
process in which most or close to all microorganisms (pathogenic or not) on skin, in wounds, on mucous membranes, clothing and hard surfaces are killed through the use of chemicals, heat or ultraviolet rays
- antiseptics are antimicrobial substance that are applied to living tissue/skin to inhibit or kill microorganisms (both transient and resident) thereby reducing the total bacterial count and reducing the possibility of infection, sepsis or putrefaction
15
Q
What are the pros and cons of 60-90% alcohols (ethyl, isopropyl or methylated spirit)?
A
PROS
- excellent antiseptics, common, inexpensive
- ethyl alcohol is less drying on the skin than isopropyl and better for frequent use.
- rapidly kill all fungi, bacteria (including mycobacteria), most viruses (HBV, HCV and HIV) on skin however - NO RESIDUAL KiLLiNG EFFECT
CONS
- not good cleaning agents - easily inactivated by organic materials such as dirt, blood, foreign bodies
- Flammable
- Damage latex over time
- Static electricity may ignite hand sanitizer if not allowed to dry before contact
16
Q
What are the pros and cons of 3% iodine (aqueous and alcohol containing tinctures)
A
PROS
- inexpensive, effective, widely available
- broad antimicrobial, kills vegetative bacteria, mycobacteria, viruses, fungi
- up to 3% non irritating to mucus membranes or skin i.e. ideal for vaginal use (unless allergic)
CONS
- little residual antimicrobial effect
- rapidly inactivated by organic materials, such as blood, sputum, foreign bodies
- absorption of free iodine through skin and mucous membranes may cause hypothyroid ism in NEWBORN INFANTS
- allergic reactions can occur, check for hx of allergy (Iodine AND shellfish)
17
Q
How long does it take for iodine to activate and what is responsible for antimicrobial activity?
A
takes 2 minutes of contact time to release free iodine - active chemical with rapid killing action
must release enough free iodine to produce adequate levels of antimicrobial activity of iodophors
18
Q
What are the pros and cons of 7.5%-10% iodophors (Betadine or Wescodyne)
A
solutions of iodine mixed with a carrier (complexing agent) such as poly vinyl pyrrolidone (povidone-iodine) that releases small amounts of iodine
Betadine (povidone-iodine) is the MC iodophor - considered BEST PRE-SURGICAL ANTISEPTIC
19
Q
What are the pros and cons of 2-4% chlorhexidine gluconate (Hebiclens, Hibiscrub, Hibitane)
A
PROS
- good alternative to iodophors
- broad spectrum antimicrobial
- SAFE FOR NEWBORN
- 6+ hours of persistent action
- minimally affected by organic matter
- RECOMMENDED CONCENTRATion 2-4%
CONS
- Increase inhibition of microorganisms with repeated use
- EXPENSIVE
- action reduced or neutralized by natural soaps, substances present in hard tap water and some hand creams
- not effective against tubercle bacillus, only fairly active against fungi
- pH > 8 decomposes
- contact with eyes causes conjunctivitis
20
Q
What are the pros and cons of hydrogen peroxide?
A
PROS
- liberates oxygen bubbles when contacts blood and tissue peroxidase - this seems to dislodge bacteria, debris and other contaminants from small crevices HOWEVER WEAK GERMICIDAL ACTIVITY
- removes blood from clothing
CONS
- can cause ULCERATION of NEWLY FORMED TISSUE and delay healing - DO NOT USE ON FRESHLY SUTURED WOUNDS
- toxic to fibroblasts
- NEVER USE IN SINUSES
- NEVER USE FOR FORCEFUL IRRIGATION
21
Q
What are surface-active agents with the cleaning properties of soap but virtually NO tissue toxicity, including eye and cornea? What is the major drawback?
A
Nonionic surfactants
- Shur-Clens
- Pharma-Clens
- no demonstrable adverse effects in wounds and lacerations
NO ANTIMICROBIAL ACTIVITY
22
Q
Which herb is an excellent solution or both pre- and post-surgical wound cleaning?
A
Calendula succus
23
Q
What is in the NCNM Minor Surgery Tincture?
A
Calendula succus: Hydtastis: Echinacea (1:1:1)
Could also have one part got kola
- Work well for all cleaning and for wound care to reduce infection and help encourage wound healing (ESPECIALLY WIHT GOTA KOLA*)
24
Q
What is green soap?
A
Causes mild wound damage yet acceptable for general wound cleaning if needed
25
What should be considered when choosing and antiseptic (4)?
- does dirt need to be removed and other materials? SOAP AND WATER
- is there a residual action? long term killing effect?
- Is the product safe? What absorption risks are there? Toxicity? Allergies?
- Cost?
26
What is the best pre-surgical antiseptic?
povidone-iodine (betadine)
27
What are the pros and cons of non-ionia surfactants?
surface-active agents with the cleaning properties of soap, but virtually no tissue toxicity (including eye and cornea)
no demostrable adveres effects in wounds and lacerations
Major drawback? - NO ANTIMICROBIAL ACTIVITY
28
Post-operative infection is determined by what risk factors?
* Number of microorganisms entering the wound.
* Type and virulence (ability to cause disease) of the bacteria
* Strength of the patient’s defense mechanisms (e.g., status of the immune system)
* External factors, such as hospital stay, surgery over 4 hours in duration, etc.
29
Know the pros and cons of shaving skin before prepping for surgery.
Do not shave hairy areas of the body, especially the eyebrows, which may not grow back.
Shaving a patient causes multiple areas of nicking of the skin, which provides a portal of entry for secondary infections.
It is proper to cut back hair with scissors (except for the eyebrows).
Surgical “clippers” are used routinely in the O.R.
Use wide tape to “pick up” the loose cut hairs.
30
Know the basics of how to establish sterile fields for the patient.
Patient:
• If the skin is visibly soiled, gently wash it with soap and clean water or alcohol before applying the antiseptic.
• Clean the skin using ever expanding concentric circles, which originate at the focus of the wound or operative site.
• This will keep the contaminated debris moving out and away from the surgical site.
• Be sure to prepare an area of skin well beyond the size of the opening in the fenestrated drape
• Dry the area before applying the antiseptic.
• Thoroughly scrub (or “paint”) with an effective antiseptic, preferably with Betadine® swab sticks, three or more concentric circles starting in the center and being careful not to miss any area of skin.
• Since Betadine® is an iodine based solution, be sure that your patient is not allergic to it!
• REMEMBER – Betadine® must be thoroughly removed after completion of the procedure!
• After the operative site has been thoroughly prepped drape it with sterile clothes or a simple fenestrated drape.
• Chose a drape that has an adhesive affixed to the back of the opening to anchor it securely so that it does not shift about during the surgery.
• Allow the antiseptic enough time to be effective before beginning the procedure.
31
Know the basics of how to establish sterile fields for the doctor.
Surgeon:
¥ Before “scrubbing” the doctor will prepare him/herself for surgery by placing a covering over his/her hair and placing a surgical mask over her/his mouth
¥ Both are optional for most routine minor surgery unless the surgeon has a URI and/or cough).
¥ Hand scrubbing is of extreme importance because this is the part of the physician's body that comes into direct contact with the surgical site even though it is gloved.
¥ If for some reason the glove tears or is punctured, proper preoperative hand scrubbing may provide that extra layer of defense necessary to prevent contamination/infection.
¥ Clean the nails with a nail file during the scrubbing operation and repeatedly cleanse (at least three times – up to 5 minutes) from the hand up to elbow always insuring that the contaminated debris is moved away from the fingers.
¥ When the scrubbing is complete hold the hands in an upright position to allow the excess water to drip off at the elbows.
¥ This will prevent contaminants from being carried back to the hands by the water.
¥ Practice proper gloving technique
32
Know the basics of how to establish sterile fields for the instrument field.
Instrument Field:
• Place sterile suture pack on a Mayo stand or other suitable table and open using proper techniques
• The sterile field also includes the air space immediately above the stand and nothing should be permitted to violate that air space or touch the stand except the gloved hands of the surgeon!
33
Know the pros/cons of using alcohol for skin prep for injections
According to WHO and its Safe Injection Global Network (SIGN), “swabbing of clean skin with an antiseptic solution prior to giving an injection is unnecessary,” as no infections were noted in controlled trials.
A review of microbiologic studies did not suggest that wiping the skin with an antiseptic before giving an intradermal, subcutaneous or intramuscular injection reduced the risk of infection
34
Informed consent implies that the patient completely understands what issues?
Informed consent implies that the patient completely understands the following:
1. The nature of the treatment
2. All material risks for the treatment
3. The possibility of risk
4. Alternative treatment(s) available and associated risks of those treatments
5. Consequences of going untreated
35
Know the meaning of PARQ and how to use it for “informed consent”.
P Procedure - This is a description of the proposed procedure, how it is to be done with as much detail as the patient wants or desires.
A Alternatives - This is a description of any and all alternatives (and their risks) to doing the procedure this way (i.e. homeopathy as an alternative to surgery, etc…).
R Risk - This is a description of any and all possible risks associated with this procedure (i.e. infection, hypopigmentation, etc…)
Q Questions - Let the patient ask questions about the procedure. Write down their questions and your answer to the questions in the chart.
It has become very obvious to physicians/surgeons that the signed informed consent form is next to useless in court. Because of this, the written consent form is helpful but cannot stand alone with regards to the legal aspect of patient informed consent.
The best combination for informed consent is both a written informed consent outlining the procedure and possible risks and an oral (PARQ) with the patient prior to the surgery.
36
Know what/what not to include in the Procedure Note portion of the MS Report.
Always indicate in the “Pre-operative Diagnosis” section the reason(s) the skin tag or wart or other suspicious lesion was removed (e.g. the patient had recurrent bleeding or pain.)
In the left hand column fill out the applicable section (i.e. Cryosurgery, Hyfrecation, etc.).
Describe the skin prep used, record the amounts of anesthesia and bicarbonate mixed, and the amount used.
Describe the suture type(s), size(s), location, and number.
List the duration of the procedure and the amount of blood lost.
Remove any unused portion of the form from the computer record
Indicate if an Oral PARQ was done.
Write a brief description of the actual procedure – do not include the details already recorded in the upper sections of the form.
Of course if the procedure is complicated include as much detail as needed!
Indicate how well the patient tolerated the procedure.
Typing “.NCNMMS FOLLOWUP” into EPIC inserts a template directly into the chart note.
Complete the blanks in the “General for all Surgery” section and any other sections that apply as you explain the instructions to the patient.
Remove unneeded section(s) from the computer record.
Print out a copy for the patient or scan a paper copy into EPIC
37
What is the concept of free margin on a pathology report?
look to make sure the report indicates the MARGINS on nth eSUBMITTED SPECIMENS are FREE AND CLEAR*
If the margin was NOT CLEAR - F/U will be needed for complete removal of the lesion
38
What is the concept of "dead space"?
dead space is an empty area left after an excision or injury
39
What is the concept, logic and importance of undermining?
* Undermining allows the skin to slide over the subcutaneous tissue more easily and stretch enough to close the opening with less tension, resulting in less scarring.
* Skin removed by trauma or along with a skin lesion leaves a hole.
* Closing this hole increases the tension on the incision and tends to cause it to want to spring apart.
* Over time, this tension will tend to cause the forming scar to widen. Undermining reduces this problem.
* Undermining is a technique to free the wound edges for closure and allow the skin edges of an incision or wound to lay together in eversion without tension.
* Can be done in any tissue plane, but typically is done between the skin and subcutaneous tissues.
* Can use careful sharp dissection with a surgical blade or sharp (e.g. iris) scissors
40
What is the preferred method to undermining?
blunt dissection with hemostat, blunt scissors or any blunt instrument
41
what are the basics of suture removal?
Proper timing is essential for a good result. Stitches taken out too soon may result in wound dehiscence. Stitches left in too long, may cause scar tissue to begin to form around the suture material “railroad tracking” scars.
1. Grasp one end of the suture or knot, shift it back and forth to free it up so you can see clearly where to make your cut
2. Cut the suture with a scissors or scalpel blade and pull the freed knot ACROSS the suture line
3. Pulling the suture out in this manner helps reduce wound “stress” and helps avoid dehiscence.
42
Name the four reasons for/advantages of using the Subcutaneous Suture (Buried Stitch)? What type of suture would you typically use?
1. provide wound stability
2. close dead space
3. help to evert the edges
4. relieve tension on the wound edge
Plain-gut or chromic-gut suture (absorbable suture materials)
43
What are the mechanisms of action for local anesthetics?
Local anesthetics prevent or relieve pain by preventing the generation and conduction of nerve impulses. Action mostly restricted to the site of application where they bind to a specific receptor site within the pore of the Na channels in nerves and block ion movement through this pore.
44
Anesthetics (OTHER THAN WHAT?) are generally?
Vasodilators
- Other than cocaine which vasoconstricts
45
Which nerve fibers are most sensitive to actions of local anesthetics?
As a rule SMALL NERVE FIBERS are MOST SENSITIVE to local anesthetics than large ones
46
True or false: Local anesthetics used at typical rates and concentrations wear off with time, typically with complete recovery in nerve function with no damage to nerve cells or fibers
TRUE
47
What can be added to tetracaine and lidocaine when used for topical anesthesia to produce vasoconstriction?
phenylephrine in various combinations
48
What are the several benefits of adding epinephrine to local anesthetics?
1. Decreases bleeding making surgery easier
2. Prolongs the duration of the anesthesia by retarding absorption at the site of injection
3. Minimizes the amount of anesthesia needed
4. Less anesthesia = decreased systemic toxicity
49
what are the potential side effects of local epinephrine injection?
epinephrine itself may induce hypoxic damage if used in areas of the body where normally there is limited circulation
```
IE DO NOT USE EPI ON:
Digits
Nose
Ears
Penis
Female genitalia
```
50
how quickly will epinephrine in a local anesthetic produce its full effect
anesthetic itself may have an immediate onset of action, but
FULL VASOCONSTRICTION with epinephrine typically requires 5-10 minutes
51
Which preparations of local anesthetics have a preservative? what is the name of the preservative?
Multiple-dose vials still contain the preservative methylparaben
52
With the administration of local anesthetics, which sensation or function disappears first and which follow in what order? In what order do they return?
In general, the sensation of pain disappears first, followed by that of cold, warmth, touch, deep pressure and finally motor function.
Typically these sensations will be recovered in reverse order to which they disappeared.
53
What are some of the major drug interactions/bad effects with local anesthetics?
Drug interactions: MAOIs, Carbamazepine, Cyclobenzaprine, Tricyclics, Tetracyclics, Phenothiazines
54
What is the characteristic allergic reaction?
* delayed appearance of skin rashes
* acute onset of localized or general urticaria (hives)
* onset of asthma.
* True allergic responses occur in less than 1% of patients receiving local anesthetics.
* Rarely, outright anaphylactic shock can occur.
55
What are the side effects of drug interactions with anesthetics?
Side effects:
• Bradycardia, hypotension, cardiovascular collapse
• Death due to ventricular fibrillation
• Sedation is the most frequent CNS effect.
• Temporary loss of consciousness
• Lidocaine can cause dysphonia, euphoria and muscle twitching.
• Restlessness and tremor can occur and proceed to convulsions, respiratory failure and death.
• Skeletal muscle – local anesthetics usually have little effect except perhaps to cause fatigue.
• Smooth muscle – local anesthetics may depress contractions of bowel smooth muscle temporary indigestion and constipation.
• Skin – Hypersensitivity may manifest as atypical asthma or local dermatitis – occur almost exclusively with ester type anesthetics.
• Uterus – usually do not suppress uterine contractions
• Epinephrine is labeled “pregnancy category C” because it has been shown to reduce uterine blood flow in experimental animals. If given late in pregnancy it may produce decreased uterine blood flow which may induce premature labor
56
What is the most frequent CNS action of local anesthetics?
sedation
| temporary LOC
57
Into which tissues is it not safe to inject local anesthetics containing epinephrine?
Epinephrine containing solutions should not be injected into tissues supplied by end arteries, including fingers, toes, ears, nose, vulva, clitoris, and penis.
*Given potential risks, it is prudent to postpone non-urgent procedures requiring the use of epinephrine until after pregnancy.
58
What is the purpose of adding sodium bicarbonate to local anesthetics?
```
REDUCED PAIN ON INFILTRATION!
Buffering lidocaine (with or without epinephrine) by adding 1 part 8.4% sodium bicarbonate to 10 parts of anesthetic raises the pH closer to the physiologic
```
FASTER ONSET OF ACTION - For Nerve Blocks
alkalization increased amounts of uncharged, lipid-soluble base to more readily cross the nerve membrane, leading to a faster onset of action
59
Can sodium bicarbonate be safely added to local anesthetic products containing epinephrine? Why/why not? What are the effects?
Epinephrine is chemically unstable in anesthetic solutions alkalinized by sodium bicarbonate–don’t add sodium bicarbonate until ready for immediate use!
Neutralizing lidocaine and bupivacaine solutions containing epinephrine with bicarbonate decreases the overall activity of epinephrine.
60
What is infiltration anesthesia?
injection of a local anesthetic directly into tissue without considering the course of cutaneous nerves
61
what are the two definitions of a field block?
1. Injection of a combination of intradermal and subcutaneous local anesthetic solution in an inverted V just proximal to the sides of the lesion that as a result will anesthetize the region distal to the site of injection, with no attempt to locate specific nerves.
¥ Blocks nerve transmission from the injected site to the brain
2. Injection of a combination of intradermal and subcutaneous local anesthetic solution completely around the boundaries of the lesion, with no attempt to locate specific nerves.
¥ Produces an anesthetized “field” inside of the boundaries of the anesthesia.
¥ Avoids injecting anesthesia directly into the lesion avoiding distortion of the anatomy of the lesion and allowing the pathologist to correctly interpret the biopsy specimen.
62
Two advantages of a field block OVER an infiltration anesthesia?
less drug can be used to provide a greater degree of anesthesia
63
What are the various routes of administration of local anesthetics?
```
topical
infiltration
field block
digit block or nerve block
intravenous regional
spinal
epidural
```
64
What are the 5 considerations when choosing an infiltration anesthetic?
1. Side effect profile
2. History of use for the patient – stick to the same anesthetic that the patient has used safely in the past
3. How long will the procedure last?
4. Is it anticipated that there will be significant pain post-procedure?
5. For both 3 and 4 above, consider a long-acting agent like bupivacaine or lidocaine w/ epi.
65
What are the maximum allowable safe single doses of plain 1 % lidocaine and 0.25 % bupivacaine alone and with epinephrine?
- 1% lidocaine: 4.5 mg/kg (30ml per average adult)
- 0.25% bupivacaine: 3mg/kg (70ml per average adult)
- 0.25% bupivacaine with epinephrine: 3.5mg/kg (90ml per average adult)
66
What alternatives to local anesthesia are available when a patient is apparently allergic to the ones commonly used?
- Use methyl paraben preservative-free, single dose ampoules to avoid reactions
- If the allergy-causing drug can be identified as an ester (tetracaine, benzocaine, procaine), use an amide (lidocaine or bupivacaine), since patients allergic to esters are rarely allergic to amides.
- injecting benadryl in place of a local anesthetic may reduce most or all of the pain
More alternatives:
¥ Use ethyl chloride locally.
¥ Place ice directly over the wound to provide a short period of decreased pain sensation.
¥ For calm patients who have small lacerations an option would be to use no anesthetic – often the pain of injection exceeds the pain of placing two or three sutures!
67
Vertical mattress sutures: advantages and disadvantages?
Advantages:
¥ Properly placed, it everts the edges better than other stitches.
¥ Helps to close a large area of dead space in a wound.
¥ It’s a strong stitch providing some added support to a wound under stress.
¥ A common role is to provide a “stay” suture to initially align and approximate a wound to be then closed with other stitch types.
Disadvantages:
¥ Proper placement is time consuming!
¥ Can result in “railroad tracking” scars if done improperly – tied too tight and/or left in place too long!
68
In what instances do topical anesthesia most likely carry the risk of systemic absorption?
Topical anesthesia always carries the risk of systemic absorption, particularly when applied to denuded skin, or in infants.
NOTE: Also, particularly rapid absorption when applied to tracheobronchial tree – systemic concentrations are nearly the same after airway inhalation as they are after intravenous injection.
69
Contrast the onset and duration of cocaine and tetracaine. Maximum doses?
Cocaine: Max Dose=200 mg, immediate onset of action
Tetracaine: Max Dose=50 mg, slow onset
70
EMLA – How quick does it work? How deep? Can it be safely used on mucous membranes?
Local anesthetic mixture of lidocaine (2.5%) and prilocaine (2.5%)
– bridges the gap between topical and infiltration anesthesia
– can produce anesthesia to a depth of 5 mm.
Typically applied as a cream, which must be in place for 1 hour to become effective
Effect can last up to 1 hour
CAUTION: Cannot be used on mucous membranes or abraded skin since it is systemically absorbed
71
What drugs are in TAC? What is a favorite situation in which it is used?
Contained tetracaine, adrenaline, and cocaine (Cocaine still continues to be used in certain cases)
Using cocaine increases the cost and raises the issues of safe storage and handling.
Preparations without cocaine are comparable in their effectiveness and are gaining favor with practitioners.
Used for scalp and facial lesions
72
What drugs are in LAT and TLE?
LAT (lidocaine-adrenaline-tetracaine)
| TLE (topical lidocaine-epinephrine)
73
When applying EMLA, TAC, LAT & TLE what precautions does the “applier” need to observe? How do you know when if has produced an anesthetic effect? Potential complications?
Precautions: Gloves are recommended to prevent absorption of drug by the caregiver.
Complete anesthesia is reached when a zone of blanching is observed around the wound.
Complications:
• CAUTION: DO NOT PUT EMLA IN AN OPEN WOUND – TOO MUCH WILL BE ABSORBED!
• NOTE: the downfall of TAC is that the cocaine component can cause seizures, arrhythmias, and cardiac arrest.
• Toxicity of LET can occur with excessive systemic absorption of the lidocaine or tetracaine—avoid by not using on mucous membranes or large wounds
74
What are the two types of vapocoolants?
Aerosol or Bottled
| Ethyl Chloride
75
what are the symptoms of respiratory involvement?
wheezing, coughing, dyspnea and sensation of chest constriction.
76
what are the symptoms of cardiovascular involvement?
hypotension
tachycardia
syncope
cardiac arrest
77
what are the symptoms of GI involvement?
nausea
vomiting
diarrhea
abdominal cramping
78
what cutaneous symptoms may occur in anaphylaxis?
urticaria (hives, wheals), pruritus, warmth and redness
79
What is the difference between immediate onset and slow onset anaphylaxis?
Immediate onset - the patient will begin to experience symptoms within minutes of exposure.
Slow (delayed) onset - symptoms occur slowly over a period ranging from 15 minutes to several hours.
NOTE: Usually the faster symptoms begin, the more severe they will be.
80
What are the likely early warning signs of anaphylaxis?
Sensations of warmth or flushing, itching, sudden fatigue, lightheadedness or a sense of "something not being right"
81
Know the protocol for treating early and late onset anaphylaxis. ALWAYS START TX AND CALL 911!
ALWAYS START TX AND CALL 911!
1. STOP the procedure: quickly put a sterile bandage over the operative site and THEN address the reaction.
2. Always have epinephrine, Benadryl and oxygen on hand before administering any injections. Administer epinephrine HCL 1: 1000, 0.3-0.6 cc subcutaneously or IM
3. Err on the side of beginning with the lower dosage and repeat every 15-30 minutes if needed.
4. The lower dosage will be less likely to produce symptoms of toxicity – such as hypertension, chest pain, excessive tachycardia, headache.
5. Administer oxygen by mask at 15L/min
6. Administer Benadryl 50 mg IM
7. Monitor for symptoms of epinephrine toxicity as outlined in #4 above.
8. If the above steps do not halt attack, start the following until the paramedics arrive:
a) Maintain open airway, insert oral airway if needed, continue O2
b) Initiate CPR if necessary.
c) Administer second dose of epinephrine and Benadryl 50mg IM.
d) Check vitals - if BP is dropping or there is respiratory distress start IV line, and adjust IV flow rate to maintain systolic BP at 90 mm/hg.
e) Consider administering epinephrine 1:10,000 (not 1:1000) 5cc IV, follow with 50 mg Benadryl IV.
82
What are the symptoms of epinephrine toxicity?
hypertension
chest pain
excessive tachycardia
headache
83
What are the epinephrine concentrations in Epi Pen and Epi Pen Jr.?
EpiPen - each pen automatically administers a single 0.3 ml dose of 1:1000 concentration
EpiPen Jr. (use in children up to 60#) – each pen automatically administers a single 0.15 ml dose of 1:2000 concentration
84
What are the “three” functions of a horizontal mattress suture?
Uses:
1. Invaluable as a “retention” or “stay” stitch (like the vertical mattress), when closing a wound under tension.
2. Used for approximating and everting wound edges (which it often does better than a vertical mattress stitch) to be followed by closure with a second, more superficial interrupted or running stitch. It is usually placed deeply and at a good distance from the wound edges.
3. Finally, it can provide hemostasis in a bleeding wound.
85
What are the risks of a horizontal mattress suture?
CAUTION: if this stitch is pulled too tightly, tissue hypoxia, and thus poor healing, may result.
86
When should you remove a horizontal mattress suture?
Removal time is variable:
¥ At the time of surgery when suturing with other stitches is complete
¥ A few days later when wound healing has begun
¥ Left in place as a “stay” stitch for a few days to weeks and be “bolstered” to keep it from cutting into the skin.
