Procedures, Wound Care, and Minor Surgical Skills
Consent, anesthesia, and closure decisions
Procedural questions reward a reproducible sequence: indication, informed consent including alternatives and risks, site verification and time-out, adequate anesthesia, irrigation, exploration, closure or dressing, and documented neurovascular checks before and after.
Know local anesthetic pharmacology: lidocaine 1% contains 10 mg/mL; maximum without epinephrine is about 4.5 mg/kg, with epinephrine about 7 mg/kg. Buffer with bicarbonate to reduce injection pain. Digital blocks traditionally use plain lidocaine; follow local protocol. Wound irrigation with normal saline under pressure reduces infection; avoid povidone-iodine or hydrogen peroxide in the wound bed. Closure timing: clean wounds may be closed up to 18–24 hours; contaminated wounds, bites, and puncture wounds are often left open or delayed. Know suture selection, adhesive strips, tissue adhesive limits, and staples.
Also understand incision and drainage technique, nail trephination, foreign body removal, epistaxis management with anterior pressure, cautery, or packing, splinting principles, and reduction of nursemaid’s elbow within scope.
Traps: closing a cat bite primarily; missing tendon or nerve injury before closure; failing to document tetanus status; using an epinephrine-containing solution in a digit contrary to policy; and applying a splint so tightly that compartment syndrome develops.
Worked example: a 70-kg adult needs laceration repair with 1% lidocaine without epinephrine. Maximum dose is 4.5 mg/kg × 70 kg = 315 mg, which equals 31.5 mL of 1% solution. Rule of thumb: document distal pulse, sensation, and motor function before and after every procedure.