NPLEX Combination ReviewMinor Surgery Topics

Paul S. Anderson, ND

Medical Board Review Services

Copyright MBRS

Universal Precautions• “Universal precautions shall be observed to prevent contact with blood or other

potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials.”

• “The blood and body fluids of all patients should be considered as potentially infectious.”

 

• These guidelines are important to protect you, your employees, and your patients. They are enforced by OSHA with site inspections and stiff fines

• The main components of Universal precautions include protective barriers and sharps management.

• Accidents involving sharps (needle sticks, scalpels) are the greatest single cause of HIV infection in the workplace.

 

• The risk of transmission of HIV after one percutaneous exposure is .3-.5% (or approximately 1:250 accidental needle sticks).

 

• Hepatitis B is the most frequently occurring work-related infectious disease in the U.S.; the risk per accidental needle stick is 6-39% (up to 75 times greater chance of transmission than HIV). This is in part because of the higher concentration of HBV in the blood; 1cc of blood diluted to 10 (.0001) still retains infectivity. In addition, HBV virus can remain active up to 6 months in dried blood.

Types of InstrumentsNeedle holder (or driver)• Blunt nosed: ratcheted; holds the needle and suture; modification of forceps/hemostats, but with stronger, shorter, wider

jaws. Tips may be toothed or smooth (toothed hold better, but can damage suture or needle if too much pressure). Tungsten carbide tipped hold better than smooth, with less damage to sutures than toothed, lasts longer, more expensive.

 

Scissors• Iris scissors: very fine; used for dissecting, trimming skin; may be curved, straight (do not use to cut sutures or bandages) • Sutures scissors: used for cutting suture• Also suture removal scissors, bandage scissors

Forceps (pick-ups)• Adsons w/teeth: used for handling tissue (the teeth cause less trauma to tissues than smooth tips)• Adsons w/o teeth (smooth): used for grasping sutures, foreign bodies, picking things up sterilely (not for tissues!)• Splinter forceps

Hemostats (also called clamps, forceps, Kelly’s, mosquitoes)• For removing scalpel blades, holding tourniquets, clamping vessels, holding skin tags and toenails, etc.; may be curved or

straight.

 

Scalpel handle, blades• Disposable, sterile scalpel blades attach to reusable handle (usually No. 3)• #11 blade: for stabbing/incising the skin in I 7 D (incision and drainage)• #15 blade: standard blade for excision, trimming, dissecting tissue• #10 blade: similar to #15, but larger, for thick, tough skin (back, scalp)

Sterilization of Instruments:Definitions• Sterilization: the destruction of all living

microorganisms, including bacterial spores.• Disinfection: the reduction of a population of

pathogenic microorganisms without achieving sterility (not all bacterial spores are destroyed).

• Disinfectant: a germicidal, chemical substance used on inanimate objects to kill pathogenic microorganisms, but not necessarily all other.

• Antiseptic: a chemical agent applied to the body that kills or inhibits the growth of pathogenic microorganisms.

Suture: Absorbable vs. Nonabsorbable

• Absorbable sutures can be further subdivided into Natural and Synthetic. – Natural sutures are made from mammalian collagen, and are eventually

digested by body enzymes, which attack and break down the suture strand.

– Synthetic absorbable sutures are polymers, which are hydrolyzed (water gradually penetrates the suture filaments, causing breakdown of the polymer chain). The different methods of breakdown cause varying degrees of tissue reaction. In general, the hydrolyzation reaction results in a lesser degree of tissue reaction than the enzymatic breakdown.

– Absorbable sutures are used for temporary approximation of wound edges, particularly subcutaneous tissues and mucous membranes, dentistry, obstetrics, deep skin wounds).

• Nonabsorbable sutures are made of metal, synthetic or organic fibers; they are not broken down in the body and are used in the skin (to be removed), or for permanent internal placement (vascular grafts, tendon repairs). Some, in reality, gradually lose tensile strength by hydrolysis; some are gradually encapsulated in fibrous connective tissue.

Other Methods of Skin ClosureSteri-Strips (Skin Closure Strips)• Self-adhesive filaments; can be used instead of sutures in many wounds (small wounds, thin

flaps, children)– Pros and cons-usually a judgment call.– Can also be a supplement to sutures-in between complicated wounds where there is excess tension or

where skin edges are difficult to evert.– Can be left or applied after some or all sutures are removed to give extra support (especially on the face if

you want to remove sutures early to prevent scarring).– Don’t allow to encircle digits (can have a tourniquet effect).

• Advantages: much less traumatic, painful; less expensive; easier to apply; doesn’t require special equipment; may cause less scarring (good for faces).

Tissue Adhesives• Cyanoacrylate tissue adhesive (Dermabond-currently the only glue FDA approved for surgical

use).– Very similar to "Krazy Glue", except sterile, doesn’t contain toxic chemicals.– Applied with applicator in 3 thin layers; takes about 50 seconds to set, allowing time for approximating skin

edges (just as important as with sutures).– Within 21/2 minutes is a strong as sutures, sloughs off of skin as wound heals within 5-10 days.

• Advantages: Eliminates need for both local anesthetic administration with needles, and surgical needles, therefore more painless. Especially useful for kids. Faster, and therefore more cost-effective. Eliminates the need for follow-up, suture removal. Easier to apply than sutures (though does require some skill, practice). Best for facial wounds, selected areas on trunk or extremities.

• Disadvantages can’t use where there is excessive motion or moisture; knees, elbows, hands/feet, inside mouth, groin areas.

Local Anesthetics

MOA Uses Adverse Effects Other

Lidocaine Reduces permeability of sodium influx into neuronal membranes.

Topical anesthesia, sedation, arrhythmia’s

Drowsiness, dizziness, may cause heart block and arrhythmias.

Rapid onset and medium duration.Amide prototype.

Bupivacaine Same as lidocaine.

Nerve block, spinal and epidural.

Same as lidocaine.

Slow onset and long duration.Amide.

NO I.V.

Procaine Same as lidocaine.

Ester prototype.Metabolizes to PABA

Which of the following is a CONTRAINDICATION for shave biopsy:

A. Hyperpigmented moles greater than 1 cm

B. Molluscum contagiosum

C. Seborrheic keratoses

D. Benign superficial lesions

In general AVOID answering that a shave biopsy is appropriate in any circumstance on board exams. In this case it certainly would be a bad choice as the basement membrane would be unlikely visualized – so definitive diagnosis would be unavailable.

Which of the following is a metabolized in the liver:A. lidocaineB. EpinephrineC. cocaineD. Procaine====================================Which of the following agents is primarily metabolized by

plasma enzymes:A. LidocaineB. ProcaineC. EpinephrineD. EMLA

Note: Procaine is metabolized to PABA an peripheral tissues and plasma.

10cc of a 1% solution of lidocaine contains:

A. 1 mg

B. 10 mg

C. 100 mg

D. 1 g

================================

1cc of of 1% lidocaine solution contains:

A. 1 mg

B. 10 mg

C. 100 mg

D. 1000 mg

INDICATIONS for adding epinephrine to local anesthetics include all the following EXCEPT:

A. Decrease oozingB. Prolong the duration of anesthetic effectC. Reduced risk in patients with severe cardiovascular

diseaseD. Decrease risk of toxic reaction by reducing

circulating levels of the local==================================================Other concerns – beyond tachycardia and hypertension – with epi

are its use (and concomitant vasospasm) in tissues of terminal prominence: Ears, Nose, Fingers, Toes, Clitoris, Penis.

Recall that some patients will have systemic catecholamine reactions following procedures with epi in the anesthetic. This is generally self limited and due to eventual peripheral metabolism of the locally injected epinephrine.

(NB: If absolutely necessary IV Mg+B6 speed COMT epi elimination in the liver)

Which of the following is a sign of local anesthesia CARDIOVASCULAR TOXICITY:

A. ShiveringB. HypotensionC. SyncopeD. Sweating ===========================================Which of the following is the best treatment for a TOXIC reaction:A. EpinephrineB. BenedrylC. LidocaineD. Oxygen

Toxicity and toxic reaction refer to systemic toxicity. This is generally caused by the transient effect of the anesthetic on the myocardium and potentially vascular musculature. Recall that local anesthetics do have a Na-channel blocking effect and this can cause the cardiovascular reaction / toxicity.

Procaine and Lidocaine have relatively short half-lives, so stabilizing the patient by having them become recumbent or in mild Trendelenberg, along with oxygen administration, often is the best way to aid in recovery.

Which of the following is an indication for NON-ABSORBABLE deep suture:

A. Tendon repairB. Ophthalmic surgeryC. Deep skin woundsD. Obstetrics=================================Which of the following suture types has the

highest likelihood of tissue reaction:A. Chromic gutB. NylonC. VicrylD. Prolene

Which of the following suture is the finest (has the smallest diameter):

A. 5/0B. 000C. 4-0D. 6/0====================================Nylon is what type of suture:A. Absorbable, naturalB. Absorbable, syntheticC. Nonabsorbable, naturalD. Nonabsorbable, synthetic

Four cardinal signs of slight finger flexion, fusiform swelling of the finger, pain on passive or active extension of the finger, and tenderness along the tendon sheath into the palm indicate:

A. Paronychia B. Purulent tenosynovitis C. FelonD. Ganglion cyst====================================Contraindication to I&D include:A. Fluctuant abscessesB. Recurrent abscessesC. Infected puncture woundsD. Foreign bodies

All the following may increase the amount of time that a wound takes to heal EXCEPT:

A. hematoma

B. accurate wound approximation

C. high tension

D. dead space

======================================

The destruction of all living microorganisms including bacterial spores:

A. Sterilization

B. Disinfection

C. Pasteurization

D. Homogenization

All the following are true regarding Universal Precautions EXCEPT:

A. The blood and body fluids of all patients should be considered potentially infectious

B. The main components include washing hands and sterilization

C. OSHA enforces Universal PrecautionsD. The employer must offer HCV vaccine to all employees who

have occupational exposure ==================================================Which of the following is included in the summary of OSHA

standards:A. Disposable gloves can be decontaminated for re-use.B. Mouth pipetting of blood is prohibited unless the employer

can demonstrate that no alternative is feasibleC. If a garment is penetrated by blood, the garment shall be

removedD. Contaminated needles should never be bent

This surgical tool is best for larger, thick and tough skin on the back:

A. Iris scissorsB. #10 bladeC. #11 bladeD. #15 blade================================Which of the following scalpel blades has a straight and

pointed cutting edge and is used for stabbing and incising the skin in I&D:

A. #11B. #3C. #10D. #15

This type of suture has less resistance as it passes through tissue and is less likely to harbor microorganisms. It ties easily but knots may slip and break easily:

A. Catgut

B. Silk

C. Nylon

D. Braided Vicryl

=====================================

Silk Braided Acrylic and Gut suture are the most resistant, causing more ‘drag’ but also holding their ties better. Nylon is like fishing line, strong but slippery – so it is nice going through tissue but likely to have its ties slip out.

Disruption of blood vessels, extravasation of blood constituents, initiation of the coagulation cascade and formation of a fibrin clot describes:

A. Granulation B. Hemostasis C. Secondary intentionD. Remodeling===========================================Wounds that are too contaminated to close initially but

may be closed after 3-4 days post tx:A. Primary intention

B. Secondary intentionC. Tertiary intentionD. Quartiary intention

This stitch is great for everting skin edges and precise approximation of wound edges with little tension:

A. Simple interrupted

B. Vertical mattress

C. Subcuticular running

D. Continuous running/baseball

===================================

This easy and most versatile stitch can cause “railroad track” scarring

A. Simple interrupted

B. Vertical mattress

C. Subcuticular running

D. Half-buried mattress

Urea paste dissolution and anti-fungal oral medications are appropriate treatments for:

A. Keloids

B. Papillomata

C. Onychomycosis

D. Plantar warts

===========================================

Simple rupture by pressure, simple aspiration, and surgical excision are all potential treatments for:

A. Ganglion cyst

B. Epidermoid cyst

C. Trichlemmal cyst

D. Wen

This stitch is used for triangular flaps:A. Vertical mattressB. Subcuticular runningC. Half-buried mattressD. Buried =====================================This stitch is placed in the dermis and is not

visible. It works best in wounds where there is minimal tension, and in clean, linear wounds:

A. Vertical mattressB. Subcuticular runningC. Half-buried mattressD. Three-Point

All of the following are variables that determine amount of time to leave sutures in EXCEPT:

A. Universal precautionsB. Type of sutureC. Tensile strengthD. Potential for scarring===========================================================Which of the following is a nutrient that is known to promote wound healing:A. Vitamin D B. BromelainC. MolybdenumD. Silica===========================================================The most common organism causing wound infections is:A. CandidaB. StaphC. NeisseriaD. HBV===========================================================Which of the following is a NONABSORBABLE MONOFILAMENT:A. CatgutB. SilkC. VicrylD. Steel

In order to remove stitches:A. Cut under the knot as close to the skin as possible and pull the stitch out

drawing wound edges togetherB. Cut over the knot as far away from the skin as possible and pull the stitch

out drawing wound edges togetherC. Cut over the knot and pull the stitch out drawing wound edges apartD. Cut under the knot and pull the stitch out drawing wound edges apart

============================================================Causes of hematomas include:A. InfectionB. Poor hemostasisC. Elimination of dead spaceD. Anesthesia

============================================================All of the following are potential causes of wound infection EXCEPT:A. Poor resistance of the hostB. High amount and pathogenicity of bacterial contaminationC. Adequate antisepsisD. Poor surgical techniques

This regional nerve block is injected into the anatomical snuff box to provide anesthesia to the lateral aspect of the proximal thumb:

A. RadialB. UlnarC. MedianD. Pollus===============================This regional nerve block is useful for providing

anesthesia to the tip of the little finger:A. RadialB. UlnarC. MedianD. Musculocutaneous

For the trunk, legs, feet or scalp, use the following type of suture and remove after how many days:

A. 3/0, 2-6 days

B. 3/0, 7-14 days

C. 6/0, 2-6 days

D. 6/0, 7-14 days

===================================

With suture choice and time in place consider location and stress on the wound. The more stress and thicker the skin (back, arm or thigh) the longer in place, and generally larger the diameter of suture required. The less tension and thickness (face) the smaller the suture and the sooner you remove it.

Cryotherapy is indicated for which of the following:A. MelanomaB. Squamous Cell CarcinomaC. Cervical wartsD. Basal Cell Carcinoma=================================================Which of the following conditions can be treated with cryotherapy

and has a low risk of complications:A. Ganglion cystsB. FelonC. Plantar wartsD. Purulent tenosynovitis====================================Indications for electrocautery include:A. Bloody fields B. Basal cell carcinomaC. Actinic keratosesD. Recently changing nevi greater than 1 cm diameter

Elliptical excision should have a length to width ratio of _____ with corners at ____ angles:

A. 2:1, 30

B. 2:1, 60

C. 3:1, 30

D. 3:1, 60

===========================================

Elliptical excisions should ideally be made with a #____ blade, initially cutting ____ to the skin

A. 10, perpendicular

B. 11, obliquely

C. 15, perpendicular

D. 15, obliquely

This is the most dangerous of all the malignant skin tumors:A. Actinic keratosesB. Basal cell carcinomaC. Squamous cell carcinomaD. Malignant melanoma============================================The indicated treatment for infections that result in a collection of

purulent material in a circumscribed and closed cavity:A. Blunt dissectionB. ExcisionC. Incision&DrainageD. Reduction Incision============================================A benign tumor of encapsulated fat arising from the subcutaneous

fascia:A. Epidermoid cystB. Pilonidal cystC. LipomaD. Carbuncle