Midterm Review Flashcards
1
Q
Primary intention healing
A
Healing of wound edges in direct contact
2
Q
Secondary intention healing
A
Non-closure of a wound
Very dirty or infected wounds
Animal bites to hands, feet
3
Q
Tertiary intent healing
A
AKA delayed closure
Refers to closure of a wound after observation (~ 3-5 days)
4
Q
What is the best thing to do to prepare the wound?
A
Thorough irrigation before closure
Pulsing works best
5
Q
Preparing the wound- irrigation
A
Remove all visible debris and devitalized tissue
Wounds not in delicate or friable tissue should be scrubbed
-Do not scrub tongue or mouth
Inspect wound to base
-Anesthetize first
-Look for FBs, tendon and muscle injuries
6
Q
Reusing open bottles of saline for wound irrigation
A
No, common route of cross-contamination between pts
7
Q
Components of nylon
A
Mono filament Time required for absorption: NA Color: black Common use: General Advantages: More secure knots
8
Q
Components of polypropylene
A
Mono filament Time required for absorption: NA Color: Blue Common use: General Advantages: strength
9
Q
Components of polyglactin
A
Multi filament Time required for absorption: 60-90 days Color: White Common use: Buried, lower layer in layered closure Advantages: Dissolves slowly
10
Q
Components of chromic gut
A
Mono filament Time required for absorption: 15-60 days Color: tan Common use: tongue Advantages: dssolves more slowly
11
Q
What size suture should be used for what part of the body?
A
3-0 for trunk
4-0 for extremities
5-0 for digits
6-0 for face
12
Q
General suture placement rules
A
Introduce the suture needle into the skin at a 90-degree angle
Suture depth should be just above bottom of wound and should be at least as wide as it is deep
VERY IMPORTANT to enter dermis at the same level as where you exited the other side of the wound
13
Q
Simple running
A
Faster, but harder to get tight and comes unraveled if any loop breaks
14
Q
Vertical mattress stitch
A
Provides layered closure with one stitch
Creates everted wound edges
Good for wound over a joint
15
Q
Horizontal mattress stitch
A
Good for high tension wounds or wounds that need to hold most of the tension on one side
16
Q
Subcuticular stitch
A
Can do interrupted or running Avoids "train track" or scar appearance Used for surgical or very clean wounds Sutures are placed upside-down to bury knots Final tail is hidden
17
Q
Special considerations in wound care
A
Shaving traumatizes skin and contaminates wound
NEVER shave an eyebrow
Take special care to align all natural (and unnatural landmarks)
Try to make any incision along natural skin tension lines
Excessively dirty wounds need recheck
18
Q
Reasons to use staples for wound care
A
Easy to use and very quick Can often be placed without anesthesia Don't require sterile technique Don't have to wrestle with tying Automatically evert wound However, leave scars
19
Q
Tissue adhesive for wound care
A
Very quick, no anesthesia or sterile technique required
Be very judicious about where and how you use it
Wound must be clean/dry
NO ACTIVE BLEEDING
May pull off sooner in an area with a lot of tension
Mostly just use for forehead and around the eyes, volar part of the arm
20
Q
Wound tape
A
Rarely used for primary wound closure
More effective for reinforcing
Sometimes used to re-approximate skin tears
Often used in conjunction with glue
Can be useful to reinforce thin skin when suturing
21
Q
Wound care
A
Keep dry and covered for 24 hrs Dirty wounds need recheck in 48 hrs No submersion for several more days Elevate (if applicable) Clean 2-3x daily with soap and water Watch for signs of infection APAP and NSAIDs for pain
22
Q
High-risk wounds
A
Wounds >12 hrs old at presentation Tooth-related wounds Crush wounds Heavily contaminated wounds Wounds of relatively avascular areas Wounds involving joint spaces, tendons, or bones Severe paronychia and felons Wounds in pts with hx of valvular heart dz Wounds in immunocompromised pts
23
Q
Tetanus prophylaxis in wound care
A
A non-tetanus prone wound in a pt who has not had a Td in the past 10 yrs
A tetanus prone wound in a pt who has not had a Td in the past 5 yrs
Any wound in an adult pt who has not had adequate immunization
24
Q
Tetanus prone wounds
A
> 6 hrs old > 1 cm deep Stellate or avulsion configuration Associated with devitalized tissue Contaminated with soil, feces, or saliva From a missile From a puncture or crush Associated with burn or frostbite
25
Suture removal intervals
```
Scalp: 6-8 days
Face: 3-5 days
Ear: 4-5 days
Chest/abdomen: 8-10 days
Back: 12-14 days
Extremity: 8-10 days
Hand: 8-10 days
Finger: 10-12 days
Foot: 12-14 days
```
26
When to add 2-3 days for suture removal times
```
Extensor surfaces
Age > 65
Diabetics
Chronic steroid use
Smokers
```
27
Informed consent for procedure/refusal
If competent can refuse
Written consent is needed before procedures
-Signature of pt by itself does not meet legal requirements
-Must give significant info to base decision on
28
Exceptions for informed consent rule
Age
Intoxication
Acute mental status change
Underlying medical conditions
29
What must you do screening exams and treat for in minors regardless of a consenting adult?
```
STI
Pregnancy
Drug, alcohol, dependency
Rape
Mental illness
```
30
AMA
Discover why pt wants to leave
Discuss tx option and potential for worsening sx or even death
Ask pt to sign AMA form with witness/family
Always document pt's mental capacity and your discussion with pt
31
Eloping
Pt leaves without you knowing
| If mental status or medical emergency can call for search and rescue
32
DNR
If not available, should resume care
Does not mean "no care"
Advanced Directive and Power of Attorney
33
Do criminals retain the right to refuse tx?
Yes, unless AMS
34
For crimes, what must clinicians do?
Report domestic violence
Comply with subpoena
Must avoid destroying evidence
Must provide MSE
35
How does EMTALA define an emergency?
A condition manifesting itself by acute sx of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health or the health of an unborn child in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.
36
What are the three main obligations under EMTALA?
1. Any individual who comes and requests must receives a medical screening examination to determine whether an emergency medical condition exists
Examination and tx cannot be delayed to inquire about methods of payment
2. If an emergency medical condition exists, tx must be provided until the emergency medical condition is resolved or stabilized. If the hospital does not have the capability to treat the emergency medical condition, an "appropriate" transfer of the pt to another hospital must be done in accordance with the EMTALA provisions
3. Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions.
37
When should one be given PRBCs?
Hgb 8-10 if symptomatic
-Pt is known to be bleeding without known source
<8 with CV dz, ACS definitely needs to be transfused
<7: just about everyone needs to be diffused
38
When does one need platelets and/or FFP in a transfusion?
With 5-7 units of a transfusion
39
What lab results can dictate the need for FFP in a transfusion?
PT 30-40
40
RF for aortic dissection
```
HTN
Pregnancy
Bicuspid aortic valve
Coarctation of the aorta
Males >55 yo
Smoking
```
41
What can be found on a CXR for aortic dissection?
Widened mediastinum
42
S/sx of aortic dissection
Severe, persistent CP of sudden onset
Pain may radiate down the back, chest, and neck
HTN on exam
Syncope
Hemiplegia
Intestinal ischemia
Valvular regurgitation
Peripheral pulses may be diminished or unequal
Diastolic murmur may be heard (aortic regurg)
Difference of SBP by 20 on the right and left
43
Workup for aortic dissection
```
CBC
CMP
UA
Lipid panel
Troponin
Remember D-dimer
CXR
ECG- look for LVH and inferior wall (II/III?AVF) abnormalities
CT- imaging of choice
MRI
TEE
```
44
What are the two types of aortic dissections?
Type A- involves the arch proximal to the left subclavian artery, treat with surgery
Type B- Occurs in the proximal descending thoracic aorta typically just beyond the left subclavian artery, treat the HTN (nitroprusside, esmolol, labetalol)
45
Potential causes of syncope
```
Pulmonary embolism
Anaphylaxis
Severe aortic stenosis
MVP
Pulmonary HTN
Sudden cardiac arrest
HCM
Cor pulmonale
Orthostatic hypotension
Hypoglycemia
```
46
When to do a CTA for chest?
PE
CAD
Trauma
Aneurysm
47
PE findings of lactic acidosis
```
Severe hypotension
Alteration in sensorium
Peripheral vasoconstriction
Oliguria or anuria
Deteriorating mental status
Tachypnea is always present when the cause of lactic acidosis is tissue hypoxia
```
48
Fungal meningitis findings
Protein: 500-2000 mg/dL
WBCs: 50-1000
Glucose: nl to slightly low
49
Bacterial meningitis findings
Protein: 50-1000 mg/dL
WBCs: 1000-5000
Glucose: low (slightly to very low)
50
Viral meningitis findings
Protein: nl to increased
WBCs: 10-1000
Viral: nl to slightly low
51
Virchow's triad
Triad of what causes vascular injury
Hypercoagulability: Changes in blood coagulation pathway, shifting balance toward coagulation
Stasis: The slowing or stopping of blood flow
Endothelial damage: Nl endothelium is antithrombotic
52
Etiology of hemochromatosis
Excess iron deposition in cells of heart, liver, pancreas, and endocrine organs d/t increased intestinal iron absorption, which then leads to iron deposition on organs such as liver, heart, pancreas, adrenal glands, testes, kidneys, etc
-Leads to organ dysfunction
-Some genetic causes also decrease levels of hepcidin, which inhibits iron absorption
MC autosomal recessive genetic d/o
MC cause of severe iron overload
Primary is more common than secondary
53
Presentation of hemochromatosis
```
Liver dysfunction
Heart failure
Hypogonadism
Pancreatic insufficiency
Hyperpigmentation
Hair loss
```
54
Lab studies of hemochromatosis
Genetic testing: examination of HFE mutations is pivotal for dx
Transferring saturation levels
Serum ferritin
Hepatic iron concentration
55
Tx of hemochromatosis
```
Therapeutic phlebotomy (decreases total body iron)
Iron chelation therapy
Dietary changes
```
56
Lab findings of lactic acidosis
```
Anion gap- elevated anion gap or clinically significant hyperlactatemia may occur in the absence of an increased anion gap
Lactate assay
Serum lactate level
ABG- metabolic acidosis
Strong ion gap
```
57
Nl CSF findings
```
Appearance- clear
Pressure: 50-175 mm H2O
Spec gravity: 1.006-1.009
Normally neg:
-Gram stain
-Culture
-Serology
Glucose: 40-80 mg/dL
Total protein: 15-50 mg/dL
RBC: none (unless traumatic tap)
WBC: 0-5/microL
Diff: 60-80% lymph, 10-30% mono
```
58
Findings on CXR, CTA , and EKG in pt with PE
CTA- tells you where the clots are
CXR- sometimes there will be findings on this (but usually not)
-Westermark's sign: prominent central pulmonary artery with local oliguria
-Hampton's hump: increased opacity from intraparenchymal hemorrhage
EKG- S1Q3T3
-Very deep S in lead I
-Deep Q in lead III
-Inverted T in lead III
59
Stable angina vs unstable angina
Stable
-Presents as substernal CP that is nonpleuritic and exertional
-CP relieved with rest or nitrates
-Sx: dyspnea, nausea, diaphoresis, epigastric pain, shoulder pain
-EKG: ST depression
Unstable:
-CP at rest
-Sx: retrosternal CP not relieved with rest or nitro, anxiety, tachycardia, N/V, dizziness
-EKG: ST depression and/or T-wave inversions
-Neg cardiac enzymes
60
Indications and contraindications for treatments in STEMI and NSTEMI
STEMI: MONA-B, except nitro in right-sided STEMI or PDE-5 inhibitor use in last 24 hrs
PCI is first choice, but can do thrombolytic therapy
Antiplatelet therapy, statins
NSTEMI: MONA-B, no nitro in PDE-5 inhibitor use in last 24 hrs, NO thrombolytic therapy, statins, antiplatelet therapy, PCI or CABG
Overall, do not give O2 >94%
61
What are the main classifications of shock?
Distributive
Cardiogenic
Hypovolemic
Obstructive
62
Definition of shock
Inadequate organ perfusion and tissue oxygenation
63
Clinical manifestations of shock
```
Hypotension
Tachycardia
Oliguria
AMS
Tachypnea
Cool, clammy, cyanotic skin
Metabolic acidosis
Hyperlactatemia
```
64
Distributive shock
Types include sepsis, neurogenic shock, anaphylaxis
| Characterized by severe peripheral vasodilation
65
Cardiogenic shock
MI, cardiac dysrhythmias
| Due to intracardiac causes of cardiac pump failure that result in reduced CO
66
Hypovolemic shock
Typically from hemorrhage
Due to reduced intravascular volume
MCC is blood loss
67
Obstructive shock
Includes:
Massive PE
Tension pneumo
Cardiac tamponade
68
General shock treatment
Oxygen
IV access
Draw blood
IV fluids
69
Total volume maximums for the different types of shock?
Obstructive shock or cardiogenic shock: 500-1000 mL
RV infarction or sepsis: 2-5 L
Hemorrhagic shock: >3-5 L
70
What is the first cardiac marker that will be elevated when someone's having an MI?
Myoglobins
71
Order of blockade of anesthesia
```
Pain
Cold
Warmth
Touch
Deep pressure
Motor
```
72
Max dosage of lidocaine
4.5 mg/kg without epi
| 7 mg/kg with epi
73
Max dosage of bupivacaine
2.5 mg/kg with epi
74
Initial sx of anesthesia toxicity
```
Perioral tingling/numbness
Metallic taste
Lightheaded/dizzy
Visual/auditory hallucinations
-Tinnitus, difficulty focusing
Disorientation/drowsiness
```
75
Components of lidocaine
```
Rapid onset (1-2 mins to peak)
Relatively short duration of action (~1 hr)
Acidic, so burns briefly on injection
-Can buffer 10:1 lido: sodium bicarb
```
76
When should epi not be included with anesthesia?
```
Ears
Nose
Fingers
Toes
Penis
```
77
What dosages of lidocaine are available?
```
1%
-MC used
2%
-Allows you to use less medicine (small spaces)
-Sometimes used for nerve blocks
```
78
Dosages of bupivacaine
0. 25%
| 0. 5%
79
Components of bupivacaine
Slower onset (5-10 mins to peak)
Longer acting (~4 hrs and up)
Commonly used for nerve blocks
Sometimes mixed with lidocaine to provide rapid onset with longer duration
Has been shown to reduce residual pain, even after it has worn off
80
Allergies to anesthesia
Lidocaine and Novocaine are in different classes of anesthetics, so an allergy to novocaine usually does not indicate an allergy to lidocaine
Many lidocaine allergies are actually rxns to the preservative in multi-dose vials
Non-traditional anesthesia
-Ice or injection with Benadryl or even saline will all provide some degree of anesthesia
81
Causes of first degree heart block
Meds
Ischemia
Lyme disease
82
Causes of Mobitz type I
Meds
| Post MI
83
What to not use in abx for diabetics
FQs
84
Reversible causes of cardiac arrest
```
Thromboembolism
Tension pneumo
Tamponade
Toxicity (TCAs, BBs, CCBs, digoxin)
Hypoxia
Hypovolemia
Hypo/hyperkalemia
Hydrogen ions
```
