Most deadly type of skin Ca

May affect iris of eye

Spreads very quickly

Leading cause of death from skin dz

ABCDE

Asymmetry

Borders-irregular

Color- variations

Diameter->6mm

Elevation

Sun exposure-light hair & eyes

Family Hx

Multiple birthmarks

Actinic Keratosis

Obvious freckles

Episodes of blistering sun burns

Outdoor work

Malignant Melanoma:

Diagnostic studies

Management

Diagnostic studies:

Skin biopsy

Dermascopy

Management:

Excision

Sentinel lymph node biopsy if thicker than 1 mm

Alpha interferon & Vaccine high risk to preven reoccurences

What are these:

Lenigo maligna

Cicral lentiginous

Intransit metastases & satellites

Nodular

layer:  Superficial

presentation:

 mild edema

No blistering

Ex. Sunburn

Layer: Partial thickness

1. Superficial-

upper 1/3 dermis

wet

weepy

fluid & filled blisters

mod edema

extreme pain

intact cap refill

2. Deep

mottling

mod edema

not as painful, some nerve fiber loss

NO cap refill

Layer:  Full dermis

Presentation:

Eschar

Severe edema

PAINLESS

Level:  Damage to UNDERLYING structure

Presentation:  NO EDEMA

TX of  Burns:

1st

2nd

3rd

4th

1st:  Silvadene cream, oral ABX, Tetanus if broken skin

2nd: Surgical excision, Graft

3rd: Surgical excision, Graft

4th: Surgical excision, Graft, Possible amputation

Burn-extent of injury:

9%=Head & Neck

9%=Arm

9%=Arm

18%=Anterior Trunk

18%=Posterior Trunk

18%=Leg

18%=Leg

1%=Genitalia

Using LACTATED RINGERS:

Adult- 4 mL/kg X %total burn surface area burned

1/2 given over 1st 8 hrs, 1/2 given over 16 hrs

Children- 3mL/kg X % TBSA burned

1/2 given 1st 8 hrs, 1/2 over 16hrs +maintenance

Used for Partial & Full Thickness burns

Obtained from unburned areas on body

Harvested by using dermatones to a thickness 0.005-0.015 inches

From mesodermal tissue

Rare

Rarely premalignant tumors

Predominate in Conn./Supportive tissue & organs of locomation:  BONE/CARTILAGE/FAT

Peak: children under 15 y/o, adults 5th decade

Soft Tissue Sarcoma:

 spread

dx

surgery tx

Spread:

Hematogenous spread

Usually to lungs if originated in extremity

DX:

Biopsy

CT/MRI

Surgery tx:

Resection, Radiation, Chemo, Isolated limb perfusion

up to 12/24 hrs

1. Irrigate & Clean

2. 2-0/3-0 Suture, Interupted 1st deep layer

2nd Superficial layer

3. Close w/ staples-Epidermis

4. Bacitracin-Keep dry & clean 48 hrs

5. Staple removal 6-8 days

think  GIFT

Genetic

INFX

Febrile

Trauma-head injury

think TITSS

Tumor

INFX

Trauma

Surgery-Cranial

Stroke

think MITTS

Metabolic

INFX

Tumor

Trauma

Stroke

Epilepsy Causes??

Metabolic

HYPO

Hypoglycemia

Hypocalcemia

Hypomagnesium

Hyponatremia

Hypoxia

Acid/Base disturbance

Epilepsy causes??

Medication

Inappropriate levels of seizure meds

Demerol-Meperidine overdose in elderly

Benzo withdrawal/intox

Barbituates withdrawal

ETOH withdrawal

High dose PCN

Intox: Lidocaine, Aminophylline, Neuroleptic

Isoniazid

Lithium carbonate/antidepressant

Insulin

Epilepsy causes??

Other

Organ failure-hepatic & renal

Other Encephalopathy/ HTN, HIV

Cerebral vasculitis

Cerebral edema

Non-seizure/ Pseudoseizure

Status Epilepticus:

??

Managment

Seizure >30 minutes, but must be tx in 10 minutes

TX:

ABC & gain IV access-2 lines

Lorazepam (Ativan)-4 mg IV slowly over 2 minutes

Phenytoin-1200 mg IV in no phenytoin

OR

500mg if Phenytoin

If Seizure PERSISTS:
Phenobarbital-20 mg/kg 100mg/min until seizure

MAXIMUM 1400mg

Head Trauma:  Basal Skull fx

Signs??

Periorbital Eccymoses-Raccon Eyes

Postauricular Eccymoses-Battle signs

CSF-rhinorrhea/ottorrhea

Hemotympanum

Possible facial fx

Possible dissection of carotids-auscultate

GCS-Glascow Coma Scale

Severity of Head injury

14-15  Mild injury

9-13  Moderate

<8  SEVERE

Glasgow Coma Scale:

what is being looked at??

GCS:

Eye Opening Response:  Score 4-1

Verbal response: Score 5-1

Motor response:  6-1

Higher the number the BETTER

Head trauma: 

What Cranial Nerves ar being looked at??

CN III-  Pupils are they reactive 

EOM

CN VII- raise eyebrows symettrically

 if not may have temporal bone fx

Head trauma:

Motor

Sensory

Motor: 

move extremities

respond to noxious stimuli

rectal tone present

Sensory: sensory levels

Reflexes-inc Babinski & Hoffman's sign

What are the clinical signs of increased ICP

intracranial pressure?

Progressive deterioration of neuro status

Unilateral / Bilateral Pupillary dilation

Asymmetrical Pupillary reaction to light

Deceberate or Decorticate posturing

Head CT ASAP

Spinal series

Type & Screen

CBC

PT/PTT/INR

Electrolyte panel

In Epidural Hematoma:

where is the bleed

&

what vessel is injured

where is the bleed:

Between dura and skull

&

what vessel is injured:

Middle Meningeal Artery

CT scan of head & cervical

MRI

Plain radiographs of cervical 

Biconvex mass

Displaces the brain from skull

Ipsilateral Blown Pupil

Subdural Hematoma:

Location

&

Vessels involved

Location

Between dura & brain surface itself

&

Vessels involved

bridging veins

(tearing of bridging veins)

Which type of hematoma is this Epidural or Subdural:

pt is unconscious at time of admission

or

Elderly present weeks later d/t fall

Subdural hematoma

Remember their is a contusion of the BRAIN itself

Which type of hematoma is this Epidural or Subdural:

 Presentation:

Brief LOC

Lucid interval for several hours

Progressive neuro deterioration

What are the clinical features/presentation of a contusion?

LOC

Loss of memory of incident

MS changes

Pupil changes

Focal neuro deficits

HA/N/V/Dizziness

H/A-sudden onset

N/V

Stiff neck-meningeal sign

LOC common

Cerebral Angiography-shows where blood is

(gold standard)

CT scan

Lumbar puncture-blood in CSF

Intraventricular drain-decrease ICP

Avoid activities that increase ICP

bending, straining, stool softner

Craniotomy

Meds

Mannitol, Loop diuretics, Steroids, Antiseizure

Signs of increased ICP:

Adults

Children

Adults:

N/V

HA

MSE changes

Neuro deficits

Seizures

Children:

Bulging fontanelles, separated sutures, letharge, V

Hydrocephalus:

Define

&

Possible cause

Define

Accumulation of CSF in the ventricles

Possible cause

Overproduction or Blockage of CSF

Tumor

Trauma

Infection

Congenital defects

THINK TTIC

Children:

H/A

V

Vision changes

Crossed eyes

Changes in eye spacing

Eye protrusion

Changes in facial & brow

Loss of coordination

Confusion & Psychosis

Change in percussion note

Dilated scalp veins

Increased head circumference

Depressed Eyes-downward gaze

Abnormal reflexes

Tranillumination of head

REDUCE & PREVENT BRAIN INJURY

Improve CSF flow

REMOVAL of Obstruction

SHUNT to bypass obstructed area

Meningitis

Encephalitis

Kinking

Blockage

Intracranial hemorrhage:

define

causes

RF

define

BLEEDING in the brain

causes

RUPTURES blood vessels w/in the head

RF

DIC, Bleeding disorder, Hemophilia, Sickle cell, Leukemia,

Low platelets, Anticoagulation

H/A-worse w/ flat position, change in position, bending/straining/coughing

N/V

MS changes, Seizures, LOC

Vision changes

Different size pupils

Uncontrollable eye movements

numbness/tingling

facial paralysis

weakness of body parts

Intracranial Hemorrhage:

DX

&

Tx

Dx

CBC, Platelets, PT, PTT, LFTs, RFTs

 CT, MRI, Cerebral Angiography

Tx

Surgical removal of hematoma

Surgical repair of structures-AVM, aneurysm

Corticosteroids & Diuretics-reduce swelling

Anticonvulsants

Analgesics

tx blood loss

Arterial-Venous malformation:

Define

Sx

Tx

Define

Abnormal connection b/w arteries & veins in brain

Sx

H/A, N/V, Seizure, Vision problems, Weakness,

 Lack of sensation, plegia, stiff neck, MS changes

Tx

Surgery

Cerebral Aneurysm:

Define

Type in brain

result of

tx

Define

Abnormal widening or ballooning of blood vessel

Type in brain

Berry aneurysm

result of

trauma or infection

tx

Goal: control sx & prevent further bleeding

Lower BP, Prevent blood flow to aneurysm

Basilar Skull FX:

Define

Clinical features

Management

Define:  Linear fx at base of skull

Clinical features:  CSF otorrhea/rhinorrhea, Battle signs, Raccoon eyes, Hemotympanum, Vertigo, decreased hearing, 7th nerve palsy

Management:  ABX-reduce meningitis, surgery

What is:

Postauricular ecchymosis

Periorbital ecchymosis

Postauricular ecchymosis:  Bruising over mastoids

"Battle Signs"

Periorbital ecchymosis:  CSF / bruising over eyes

"Raccoon Eyes"

Depressed Skull Fx:

Pathology

most common locations

Pathology:  results from high energy direct blow to a small surface area of skull with blunt object-bat

most occurence where:  Frontal/parietal area