EMS 2 Quiz

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Questions and Answers

During the scrubbing process, what should be done if you accidentally touch a non-sterile object with your hand?

Continue scrubbing and add one minute to the scrub time for the contaminated area. (correct)

Rinse the contaminated area with sterile water and continue scrubbing.

Immediately discard your gloves and start the scrub over.

Use an antiseptic wipe to clean the contaminated area and continue scrubbing.

Which of these statements regarding the use of epinephrine with local anesthetic is CORRECT?

The maximum dose of lidocaine with epinephrine is 5mg/kg.

Epinephrine can be used with local anesthetic in any location of the body.

Epinephrine can increase the duration and depth of anesthesia when combined with local anesthetic. (correct)

Epinephrine should not be used with local anesthetic in areas with rich vascular supply.

In the context of sterile technique, what is the goal of skin preparation before a surgical procedure?

To remove all bacteria and debris from the surgical site.

To reduce the number of microorganisms on the skin to an acceptable level. (correct)

To create a barrier between the patient's skin and the sterile surgical instruments.

To prevent the spread of infection from the patient to the surgical team.

What is the correct sequence for applying Betadine during skin preparation?

Apply Betadine in a circular motion, starting from the center and working outwards. (D) Signup and view all the answers

Which of the following statements regarding the use of sterile towels during surgical scrubbing is CORRECT?

Sterile towels should only be used to dry the hands, not the surgical attire. (A) Signup and view all the answers

When scrubbing your hands and arms, why is it important to keep your hands higher than your elbows at all times?

To prevent bacteria-laden soap and water from contaminating the hands from the elbows. (B) Signup and view all the answers

What is the primary goal of maintaining a sterile field during a surgical procedure?

To prevent the patient from developing an infection after surgery. (A) Signup and view all the answers

During the surgical scrubbing process, why is it important to rinse your hands and arms in one direction only, from fingertips to elbow?

To prevent the back-and-forth motion from introducing new bacteria to the previously scrubbed areas. (B) Signup and view all the answers

What is the recommended method for applying Betadine during skin preparation?

Circular, starting from the center and working outwards. (D) Signup and view all the answers

What is the most common cause of postoperative fever in the first few days after surgery?

A normal physiological response (D) Signup and view all the answers

What timing of fever would be indicative of an infectious source if it occurs on postoperative day 3?

Urinary tract infection (B) Signup and view all the answers

Which of the following risk factors indicates a nearly 100% likelihood of associated bacterial infection when present?

Three or more specified risk factors (A) Signup and view all the answers

On what postoperative day is aspiration most likely to cause fever?

Postoperative Day 2 (C) Signup and view all the answers

Which mnemonic represents a postoperative day associated with deep vein thrombosis as a cause of fever?

Walking (A) Signup and view all the answers

Which of the following is NOT a key step in scrubbing and gowning, according to the provided text?

Wearing artificial nails or nail polish for hygiene (A) Signup and view all the answers

The text emphasizes that the most widely used method of sterilization is autoclaving due to its ability to rapidly sterilize devices while being relatively inexpensive and nontoxic. What other key advantage does autoclaving offer?

Autoclaving effectively sterilizes a wide variety of materials used in surgery (D) Signup and view all the answers

The text states that most microbes on the hands come from which area?

Beneath the fingernails (D) Signup and view all the answers

What is the primary objective of sterilizing instruments and materials used during surgery?

To minimize the risk of infection for the patient (B) Signup and view all the answers

Which statement accurately reflects the text's description of the importance of scrubbing and gowning?

Scrubbing and gowning are essential for aseptic technique, ensuring sterility during surgery. (B) Signup and view all the answers

Why are nailbrushes generally discouraged for surgical hand scrubbing?

They can damage the skin and encourage shedding of cells. (C) Signup and view all the answers

What is the primary rationale for using a non-medicated soap for hand washing before entering the operating theatre?

Medicated soaps can irritate the skin and cause allergies. (C) Signup and view all the answers

What is the purpose of hemostasis in wound management?

To initiate the healing process by stopping bleeding (A) Signup and view all the answers

Which type of healing occurs when tissue is cleanly incised and accurately reapproximated?

Primary healing (C) Signup and view all the answers

What can excessively tight closure of a wound lead to?

Hernia formation or infection (A) Signup and view all the answers

Tertiary healing involves maintaining the wound in a moist environment for how long before closure?

5 days (B) Signup and view all the answers

Which type of wounds generally heal by secondary intention?

Infected wounds and burns (C) Signup and view all the answers

What is the main risk of immediate closure of a wound without achieving bacterial balance?

Higher risk of infection (A) Signup and view all the answers

What is a key benefit of tertiary healing compared to primary healing?

Achieves bacterial balance prior to closure (A) Signup and view all the answers

What is meant by 'healing by secondary intention'?

Granulation tissue forms and covers the defect (A) Signup and view all the answers

Which principle is NOT part of the basic management of a surgical wound?

Immediate patient discharge (D) Signup and view all the answers

What occurs during primary healing of a wound?

Tissue repair usually proceeds without complications (C) Signup and view all the answers

What is the primary purpose of wound dressings?

To provide an ideal environment for wound healing (A) Signup and view all the answers

In which situation is a dressing contraindicated?

For infected and/or highly exudative wounds (C) Signup and view all the answers

What type of dressing is known for its ability to absorb excess moisture?

Absorbent dressing (C) Signup and view all the answers

Which of the following statements about alginates is correct?

They are ideal for wounds with skin loss and medium exudation. (B) Signup and view all the answers

What is the role of hydrophilic components in composite dressings?

To aid in absorption (C) Signup and view all the answers

What should be done to prevent desiccation and infection with nonadherent dressings?

Seal the edges with a secondary dressing (D) Signup and view all the answers

What is true about occlusive and semiocclusive dressings?

They are permeable to water vapor and oxygen. (C) Signup and view all the answers

What is the correct procedure for protecting a wound during showering?

Pat the wound dry after showering (D) Signup and view all the answers

What can occur if a wound is kept exposed rather than covered?

Increased risk of necrosis (B) Signup and view all the answers

Which of the following materials is considered absorbable in wound care?

Collagen (A) Signup and view all the answers

Study Notes

ESM I Week 2 Objectives

ESM7: Describes the mechanism of aseptic technique, including disinfection, sterilization, instrument/surgical packs, scrubbing and gowning, skin preparation, and surgical asepsis rules.
ESM8: Describes the physiologic effect of surgical procedures on blood and hemostasis, and wound healing.
ESM9: Discusses risk factors, pathophysiology, diagnosis, and initial management for postoperative complications such as emboli (DVT, fat, and air embolism).
ESM10: Recognizes common postoperative infections, including microbial causes, typical onset times, preventative measures, and initial treatment options.

Surgical Patient Approach

Pre-op Management: Discussed last week
OR Prep: ESM 7
Surgical Operation: Performed throughout the course
Wounds: Post-operative recovery & complications
Disposition: Throughout the course
Documentation: Multiple notes throughout the surgical process (EENT Week 1)

OR Prep (ESM 7)

Sterilization: Uses saturated steam under pressure (autoclave), is relatively inexpensive and nontoxic, and can be prepackaged or made.
Reprocessing Steps: Includes storing, sorting, sterilization, packing, and inspection of instruments.

Scrubbing and Gowning

Essential for perioperative practice
Includes scrubbing 101, gowning and gloving, and self-gowning technique
Key Step Details:
- Keep nails short and pay attention to them when washing your hands
- Don't wear artificial nails or nail polish
- Remove all jewelry before entering the operating theatre.
- Wash hands and arms with a non-medicated soap or, if visibly soiled.
- Clean subungual areas with a nail file. Nailbrushes are not used, as they damage skin and encourage shedding of cells. Use only if necessary and should be sterile, once only (single use)
Essential steps for scrubbing include:
- Properly scrub all sides of fingers, between fingers, the back and front of the hands for 2 minutes.
- Move to scrubbing arms, keeping hands above elbows to prevent recontamination.
- Wash each arm (wrist to elbow) for 1 minute.
- Repeat the process on the opposite hand and arm, extending the scrub time by an additional minute for any areas the hand touches after the initial scrub.

Skin Preparation of the Patient

The skin is cleaned using sterile technique.
Apply Betadine in circular motions, starting from the center and working outwards.
Drape the area.

Rules of Surgical Asepsis

Goal: Maintain the sterile field.
If contact with unsterile objects, discard or re-sterilize the objects.
If questionable sterility, assume it is unsterile
Never turn your back on the sterile field.
Keep sterile gloved hands in view (above the waist and below the neckline).

Sterility Conclusion

Know how to scrub in
Watch gowning and gloving videos
Know skin prep steps
Know how to maintain surgical asepsis

Perform the Procedure

Follow instructions of the surgeon and OR team

Wound Closure (ESM 8)

Analgesia: Uses lidocaine (max 3mg/kg), with epinephrine (max 7mg/kg). Important to not administer epinephrine in or near appendages.
Clinical Wound Management: Includes hemostasis, wound closure, and wound dressing.
Hemostasis: process that stops bleeding. In most wounds, hemostasis is spontaneous; however, significant injury or lacerations may need intervention to reduce bleeding, and aid in hemostasis
Wound Healing: Describes primary, secondary, and tertiary healing.
Primary Wound Closure: Detailed steps for closing deep layers with nonabsorbable sutures, subcutaneous tissues with absorbable sutures, approximating skin edges using methods like dermal sutures, or staples, reinforcing with skin tapes, and dressing the wound.

Sutures

Ideal suture material is flexible, strong, easily tied, and securely knotted.
Minimize tissue reaction and avoid serving as a nidus for infection
Pick the smallest suture needed—to hold wound layers in approximation

Suture - Read the Packaging

Type of Suture: Absorbable vs non-absorbable, braided vs monofilament
Size of Suture: 3-0 is smaller than 2-0
Type of Needle: Tapered vs cutting

Suture Material

Non-absorbable Sutures: Not dissolved by body, must be removed, less scarring (faster removal time), primarily used on skin.
Absorbable Sutures: Dissolved by body, no need removal, best suited for under-skin use; warns of increased scarring potential if non-removed.
Braided Sutures: Twisted strands, easier to tie, risk of bacterial harboring from gaps.
Non-braided/Monofilament Sutures: Single strand, reduces infection risk, frequently used in skin closure and infection-prone wounds

Suture Size

Uses specific suture sizes based on areas of the body, ranging from fine ophthalmologic and microsurgeries to larger areas like abdominal walls, arterial lines, and orthopaedic procedures.

Types of Needles (page 26)

Cutting: Preferred for skin
Tapered/Round: Used on delicate tissues inside the body
Double-armed: Used at both ends of the suture

Wound Dressings

Purpose: Provide an ideal wound healing environment
Functions; Covering to prevent further damage; Compression to provide homeostasis and limit edema; Control hydration/oxygen tension
Allows for gas and water vapor transfer; Promotes dermal collagen synthesis and epithelial cells migration; Minimizes tissue desiccation
Contraindicated in infected or highly exudative wounds
Types: Primary, secondary, nonadherent (paraffin, petroleum jelly, etc.), occlusive/semi-occlusive (waterproof & impervous), hydrophilic/hydrophobic (composite dressings), absorbable dressing materials (collagen, gelatin, oxidized cellulose), medicated dressings (drug delivery systems)

Disposition

Wound care: Frequency of dressing changes; When to shower/avoid baths; Pat dry; Protect the wound for a sufficient amount time to minimize scarring
Follow-up: Signs and symptoms of infection; Routine check-ups; Urgent concerns
Work/school excuses

Surgical Complications

Postoperative Fever; Emboli (DVT, fat, air); Infections (SSI, UTI, Pneumonia, Intravascular catheder Infection, Peritonitis); Bacteremia/Sepsis

Postoperative Fever

What is a fever?: Temperature above 38°C (100.4°F) and is common after surgery
The cause is usually a normal physiologic response.
Differential diagnosis for fever: Surgical site infection, other hospital-related conditions, PNA, drug fever, DVT, etc.

Timing of Fever

Immediate: Starts during or within hours of surgery
Acute: Onset within the first week of surgery
Subacute: Onset within one to four weeks of surgery
Delayed: Onset more than one month after surgery

Immediate: Medications, blood products, trauma, infections, malignant hyperthermia
Acute: Nosocomial infections, viral infections, UTI, SSI (Streptococcus, E. coli, Clostridium), and myocardial infarction.
Subacute: Surgical site infection, central venous catheters, antibiotic-associated diarrhea, febrile drug reactions, and thrombophlebitis
Delayed: Infection, some SSIs, viral, or parasitic infections
Risk Factors: preoperative trauma, ASA class above 2, fever onset after the second postoperative day, initial temperature elevation, high postoperative white blood cell count, and high postoperative serum urea nitrogen

Helpful W's Mnemonic

Waves (POD 0) –acute MI EKG
Wind (POD 2) – Pneumonia, PE, aspiration, atelectasis
Water (POD 3)– UTI
Walking (POD 5 +) – VTE
Wound (POD 5-7) – SSI, Infection
Wonder drugs/What did we do? -Drug fever

Postoperative Fever Approach

Not every patient needs diagnostic testing
Thorough chart review, history, & physical essential
Discontinue unnecessary medications & catheters.
Evaluation of the patient based on history, symptoms, and physical findings.
Obtain diagnostics guided by your evaluation.

Postoperative Fever Treatment

Scheduled antipyretics (acetaminophen) for 48 hours for patient comfort.
Antibiotics generally not indicated early in the postoperative course, only indicated in critically ill or hemodynamically unstable patients; causes must be determined if used. If no cause found after 48 hours, antibiotics should be discontinued.
Tailored evaluation/management based on the individual patient, with unnecessary medications and catheters discontinued.

Thromboembolism

Virchow's Triad
Hypercoagulable state, stasis, and endothelial damage
Diagnosis: US of Leg, D-dimer
Treatment: Minor – oral anticoagulants; Extended DVT – can consider tPA infusion
Prevention: Limit surgical time, SCDs, early mobilization, anticoagulant therapy
Risk Factors: Trauma, cancer, operations of the pelvis, nonmodifiable (thrombophilia), and modifiable (type of surgery, central lines, HRT)

Fat Embolisms (FES)

Rare condition, associated with orthopedic trauma
Presence of fat globules in pulmonary circulation
Clinical features: hypoxemia, neurologic abnormalities, petechial rash
Imaging: CT chest, CT/MRI brain (neuro symptoms)
Treatment: Supportive care
Prevention: Early immobilization of fractures, limiting intraosseous pressure in orthopedic procedures

Air Embolisms

Rare complication in cardiac, neurological, and ENT surgeries
Result: Air entering the vasculature; pressure gradient to the vasculature; and direct communications, air enters the venous circulation; incomplete filtration; air introduced directly into the arterial system; or paradoxical embolization.
Clinical manifestation: Sudden onset respiratory distress (venous), neurological event (arterial), and/or a known risk factor
Diagnosis: Imaging, but often retrospective
Symptoms:
- Pulmonary: Dyspnea, gasp reflex, sucking sounds
- Cardiac: Substernal chest pain
- Neurologic: Sense of doom, dizziness/lightheadedness
- Skin:
- Ocular
Treatment: Supportive therapy (O2, pressor support, positioning); Definitive therapy in some cases (hyperbaric oxygen, HBO therapy, withdrawing air from right atrium), and cardiac massage.

Postoperative Complications Infections

Surgical Site Infection (SSI): Staphylococcus, Streptococcus, Escherichia, others
Typical time of onset within 30 days
Preventative measures: Strict aseptic technique during surgery
Initial treatment: Antibiotics specific to suspected pathogen
Urinary Tract Infection (UTI): Escherichia, Klebsiella, Proteus
Typical time of onset within 7 days
Preventative measures: maintain catheter hygiene
Initial treatment: Broad-spectrum antibiotics (based on antibiogram), followed by antibiotics based on urine culture results
Pneumonia (Hospital Acquired): Staphylococcus, Streptococcus, Gram-negative bacteria
Typical time of onset 48 hours to a week
Preventative measures: Early mobilization, respiratory exercises.
Initial treatment: Empiric IV antibiotics, followed by antibiotics based on culture/sensitivity.
Intravascular catheter infection: Staphylococcus aureus, Streptococcus, Gram-negative Bacteria (Escherichia coli, Klebsiella)
Typical time of onset: Any time
Prevention: Sterile Technique; avoid dirty areas.
Treatment: Blood culture from catheter, peripheral site; catheter removal and culture (rarely exchange); Empiric antibiotics to be followed up with culture-guided antibiotics.
Peritonitis: Escherichia coli, Enterococcus, Clostridium(spontaneous or secondary)
- Spontaneous: Idiopathic
- Secondary: Intraabdominal infection or irritation (bile, blood, barium, gastric acid, etc.)
- Typical time of onset: Sudden, symptoms within hours
- Prevention: Careful surgical techniques
- Treatment: Intravenous antibiotics; may require surgery.

Bacteremia/Sepsis

Microbial Causes: Staphylococcus, Escherichia, Klebsiella.
Typical time of onset: 48 hours-weeks.
Preventative measures: Strict aseptic technique during central line insertion
Initial treatment: Broad-spectrum IV antibiotics
If an infection occurs; it could be traced to the complications previously discussed in the powerpoint. Typically, patients will present with s/s of infection. Check blood cultures, check urine, do additional imaging if needed (ventilator patient)

Questions (page 62)

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Test your knowledge on the essential protocols for surgical scrubbing and skin preparation. This quiz covers the correct procedures to maintain a sterile environment during surgical operations. Identify the key principles and practices that ensure patient safety and minimize infection risks.