Minor Surgical Procedures: IDMT Guidelines

Objective

• The aim is to identify operating principles for minor surgical procedures.

Overview of Minor Surgical Procedures

• Minor procedures covered include digital anesthesia, incision and drainage (I&D) of abscesses, toenail removal, and advanced wound care.

Informed Consent

• Before any minor surgical procedure, the Independent Duty Medical Technician (IDMT) must get a signed patient consent using SF 522, titled Medical Record Request for Administration of Anesthesia and for Performance of Operations and Other Procedures.
• This form can be standardized by your Medical Treatment Facility (MTF).

Minor Procedure Background

• According to AFI 44-103, The Air Force Independent Duty Medical Technician Program, IDMTs can perform certain minor surgical procedures, including simple wound closure, toenail removal, and opening/draining small abscesses.
• IDMTs are restricted from suturing lacerations or performing I&D in specific cases.

Restrictions for IDMTs

• Situations where IDMTs cannot suture lacerations or perform I&D:
  • Crossing the vermilion border
  • The eyelid
  • Cartilage, like the nose or ear
  • Openings over joint spaces with tendons involved or deep muscle exposed
  • The genital or anal region
  • Palms or soles, unless directed by a preceptor

Digital Nerve Block

• This provides anesthesia to the entire digit.
• It's an excellent block for finger and toe conditions or injuries.
• Two nerve sets, dorsal and palmar/plantar, run along the digit's lateral and medial edges, providing sensation.
• A single entry point on the digit's dorsal aspect can reach both the dorsal and plantar/palmar nerves when performing a digital block.

Digital Nerve Block: Step-by-Step Directions

• Gather all needed supplies like needle, syringe, anesthetic, and gloves.
• Clean the site with antimicrobial soap and water or povidone-iodine, then let it dry.
• Check the digit's circulation (cap refill) and sensation.
• Use the anesthetic of choice, lidocaine without epinephrine is the most common.
• Use a 25 or 27 gauge needle to draw up 3ml of anesthetic into a syringe.
• Inject at the dorsal portion of the digit, inserting the needle down the bone's side at about the 2-o'clock position.
• Avoid puncturing through the palmar surface of the digit.
• Aspirate to prevent inadvertent vascular puncture.
• Inject 1 ml of anesthetic solution.
• Inject another 1 ml of anesthetic solution while withdrawing the needle back to the skin surface
• Do this again at the 10-o'clock position.
• Reassess cap refill and sensation.
• Cap refill should be normal.
• Sensation should be diminished.
• More anesthesia may be required if the area is not numb.

Abscess Information

• An abscess is a soft tissue infection, often from staphylococci aureus infections.
• Leukocytes and cellular debris accumulate in a "pocket" over time because of the colonizing organism; this becomes the abscess.
• Loculation and walling off of products lead to the formation of an abscess that looks like a honeycomb.
• Draining the infection's products by opening the abscess is the only effective treatment, allowing the tissue to heal inside out.

Incision and Drainage (I&D) of Abscess: Step-by-Step

• Obtain patient consent by accomplishing a SF 522.
• Explain possible complications, including residual local numbness, injury to deep nerves and blood vessels, poor/delayed wound healing, and residual scarring.
• SF 522 includes incision and drainage, potential risks like bleeding, infection, pain, and alternatives.
• For the procedure, the area is cleaned, numbed with anesthetic.
• The abscess is cut open with a scalpel, and the material inside is gently expressed or removed.
• The opening is probed and washed with sterile fluid.
• The open cavity may be filled with sterile gauze, and the area is bandaged, depending on the abscess's size and location.

I&D Supplies

• Supplies needed include a number 11 or 15 scalpel blade, povidone-iodine, sterile drape, hemostats, gloves, and eye protection.
• Gather an irrigation syringe, saline, a bandage, an 18 or 25 gauge needle with syringe, and anesthetic (Lidocaine without Epi).
• Clean, and drape the area.

Steps during the Procedure

• Local anesthesia is provided by approaching the abscess from the side and slowly infiltrating the skin, avoiding injection into the abscess.
• Alternatively, a "field block" can be performed by injecting anesthetic superficially around the abscess in a diamond shape.
• Once the sensation is reduced, incise over the greatest fluctuance.

Incision Info

• Ensure that the incision is big enough for proper drainage.
• If the incision is too small, it might shut too soon, not promote effective drainage.
• Then express as much pus as possible with gentle compression.
• To break up any loculations, insert a hemostat, opening and closing the jaws in the abscess cavity.
• Finally, irrigate the cavity with saline.

Abscess Packing Info

• Most abscesses do not need to be packed with gauze.
• Packing is a painful process.
• If there is an exception like a Pilonidal cysts, abscesses greater than 5cm in diameter, or for diabetic or immunocompromised patients, packing would be more necessary.

Post Procedure Info

• Provide the patient instructions for when to return for evaluation if needed.
• Antibiotics are generally unnecessary in abscesses without cellulitis surrounding them.
• If there are multiple lesions, extensive surrounding cellulitis, a history of MRSA, or failed initial incision & drainage therapy, consider antibiotics.

Ingrown Toenails

• Ingrown toenails occur when irritation of the tissues surrounding the nail lead to overgrowth, obliterating the space between the nail fold and the nail.
• Causes of ingrown toenails include improper nail trimming, using sharp tools to clean nail gutters, tight footwear, rotated digits, and body deformities.
• Improper trimming should be straight across rather than rounded at the corners.
• The great toe is most commonly affected and presents with inflammation/swelling, redness/erythema, and purulent discharge as a sign of infection.
• Simple treatments for no infection include:
  • Elevating the nail with a wisp of cotton between the nail plate and skin.
  • Daily foot soaks.
  • Avoiding pressure on the nail.
• Partial toenail removal is the best treatment if granulation or infection is present.

Toenail Removal: Step-by-Step Instructions

• Obtain patient consent by accomplishing SF 522.
• Supplies consist of mosquito forceps or nail elevator, nail splitter or scissors, forceps, gloves, providone-iodine, rubber band, glove finger, and small Penrose Drain.
• Additional supplies are non-adherent gauze, bandage, sterile drape, 25 or 27 gauge needle with syringe, anesthetic, and antibiotic ointment.
• Clean and drape area and place a digital block.
• Tie the glove finger, rubber band, or Penrose Drain around the proximal portion of the digit to minimize bleeding during the procedure.
• Slide the mosquito forceps or nail elevator between the nail and nail bed of the affected side from the tip of the nail to the cuticle.
• Try to angle the tip upward against the nail plate to minimize trauma to the nail bed.
• Cut longitudally to the entire affected area (roughly 1/3 of the nail width) from tip to base, including the cuticle.
• Make a single cut along the length of the nail plate.
• Then grasp the nail using forceps, remove from the nail groove using a rocking motion.
• Place non-adherent gauze with antibiotic ointment on the wound and cover with a bulky dressing.
• Consider oral antibiotics if there are extended field operations, concerns, or evidence of an infection.
• Inform patients to keep the site clean and dry until healed and teach proper nail trimming technique.

Advanced Wound Care: Lacerations

• Lacerations in the skin allow bacteria and foreign bodies to enter the body, which in turn can cause a wound infection.
• Cleansing, irrigating, and suturing the wound decreases the incidence of wound infections.

Laceration Repair: Step-by-Step

• Obtain patient consent by accomplishing a SF 522 that includes the diagnosis, risks, alternatives, procedure regarding laceration repair.
• Gather supplies that include gloves, antibacterial soap and water or povidone iodine, Irrigation Syringe, Sterile Saline, and 18 or 25 gauge needle and syringe.
• Additional supplies needed are:
  • Anesthetic (Lidocaine With or with Epi are the most common), but do not use with epi on digits
  • Sterile drape
  • Suture Kit/ Sutures
  • Fine scissors
  • Tissue forceps

Step by Step Instructions

• Drape affected area.
• Shave if needed to increase visibility.
• Ensure this is before cleaning the wound area.
• Clean area and tissue.
• Use antimicrobial soap and water or povidone iodine and allow it to dry.
• Prevent it from entering the wound.
• Provide local anesthesia to both sides of the wound.
• Once the wound is diminished, irrigate the wound with sterile saline.
• All material should be removed.
• Debride if necessary to remove foreign particles, mutilated, dead tissue.
• After the the would requires irrigating again to remove materials.

Closing the wound

• Wound closure promotes, approximates, and edges
• Do not close id signs of infection are present in the skin surrounding or in the wound itself
• Select appropriate material and size, synthetic non-absorbale sutures and generally used

Suture Details

• Depends on tissue that supports
• Low number means diameter
• Hold forceps perpendicular to needle.

Suturing technique

• pass epidermal dermal layers
• Thickness varies depending on body
• Square knot hold forces, and make perpendicular apply hand wrapping.
• End is wrapped over surround.

Details on ending Procedure

• grasp with surrounding pull through.
• Hands apply loop.
• Tension lateral suture end.
• Time depending on loop.
• Lateral tension.
• Sutures how many place and close.

Post Procedure

• Have suture remove
• Frame removal and suture depend sutures
• Clean with antimicrobal
• Use the cutter remove sutures, on the knotted number, ensure the area is sterile and without loose material.