Common Office Procedures Baby Health Service Lexington, KY Spalding University Louisville, KY

1. Common Office ProceduresBaby Health ServiceLexington, KYSpalding UniversityLouisville, KY Delwin B. Jacoby, DNP, APRN

2. Delwin B. Jacoby, MSN, APRNhas no financial interest or affiliations with any entities regarding this content – April 17, 2013

3. Objectives for Common Office Procedures • Review AHA recommendations for antibiotic prophylaxis for common office procedures. • Demonstrate removal procedures for veruccae and acrochordons. • Discuss management of subungual hematomas. • Develop a plan for the management of ingrown toenails. • Demonstrate correct procedure for a digital nerve block in both hands and feet. • Perform incision and drainage of an uncomplicated abscess and paronychia. • Demonstrate procedures to biopsy suspicious lesions– shave biopsy, punch biopsy, and elliptical excision.

4. Overview of Simple Office Procedures • Can be performed in most any office • Requires the following: • good light source • exam table • mayo stand/table • basic instruments and equipment • protective gear • anesthesia • suture material

5. Basic Instruments & Equipment • Scalpels, scissors, punches • Forceps • Undermining scissors • Hemostats • Needle holders • Syringes and needles • Cotton swabs • Liquid nitrogen/cryo • Gauze pads • Suture material • English Nail Anvil *

6. Universal Precautions&Sterile Technique

7. Antibiotic Prophylaxis • April 2007 - New AHA guidelines for antibiotic prophylaxis • Prosthetic cardiac valve • Previous infective endocarditis • Congenital heart disease only in the following categories: • Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduits • Completely repaired congenital heart disease with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure* •  Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) • Cardiac transplantation recipients with cardiac valvular disease

8. Acrochordons (Skin Tags) • Commonly found on neck, axilla, bra-line, groin • Topical Anesthesia +/- • EMLA • Cetacaine spray • Grasp tag with forceps and snip base with sharp scissors • Apply pressure for hemostasis and dress • Review S & S of infection • No follow-up needed • Few complications

9. Acrochordons (Skin Tags) CPT - 11200 - Removal any method of up to 15 tags any area CPT – 11201 – Removal of each additional 10 lesions.

10. Warts • Common, generally benign condition of viral etiology • Challenging!!!! • Commonly spread by auto-inoculation • Cosmetically unappealing • Often resolve spontaneously • Tend to be recurrent no matter the treatment option • Occur most commonly in children

11. Types of Warts (Verrucae) • Verruca vulgaris – common warts • Periungual warts – occur around nails • Verruca planus – flat warts • Verruca plantaris – plantar warts • Condylomata acuminata

12. Warts • Epidermal overgrowths caused by HPV. Spread by direct contact. • HPV type 1,2,4 – Assoc with Plantar Warts (verruca plantaris) • HPV type 3 &10 – assoc with Flat Warts (verruca planus) • HPV type 16,18,31 assoc with genital warts –assoc with genital cancers (condylomata accuminata). • HPV 2,4,7,27,29 – Assoc with common warts (verruca vulgaris)

13. Verrucae

14. Common Treatments for Warts Chemical Destruction Salicylic Acid Podophyllin/Podophylloxin Trichloracetic acid Bichloracetic acid Others Immune system modulator – Imiquimod (Aldara) Cryotherapy Liquid nitrogen Duct Tape?!?!

15. Cryotherapy • Application of extreme cold to destroy lesions • Easy to use • Quick • Generally good results with little scarring • No local anesthesia needed/pain tolerable • Multiple lesions can be treated

16. Cryotherapy - Disadvantages • Initial cost and set-up • Postoperative pain • Lesion recurrence • Hypopigmentation may occur • Repeat visits common • Occasional scarring

17. Cryotherapy - Precautions • Previous Rx to cryotherapy • Do not use on suspected cancerous lesions • Caution around nails and nailbed • Do not use on eyelids, elbow, digits - relative contraindication • Nose, ears, lips, ant. tibial area - caution • Dark skin • Vascular compromise • Immunocompromised patients

18. Cryosurgical Systems • Liquid nitrogen - 196 degrees C • Verruca-Freeze (chemical refrigerant) - 70 degrees C • Histofreezer (chemical refrigerant) - 55 degrees C

19. Cryosurgery

20. Cryosurgical Products

21. CryosurgeryTechniquesCPT - 17000 – Destruction benign or premalignant lesion by any method, first lesion.CPT – 17003 - Destruction benign or premalignant lesion by any method, 2nd – 14th lesion.

22. Cryotherapy - Veruccae

23. Nail Anatomy

24. Subungual Hematoma • Painful accumulation of blood under the nail secondary to trauma • Evacuation relieves pain • > 50% of nail bed involvement suggests sig. laceration and possible fracture. • Assess neurovascular function prior to procedure • Patient education and expectations are very important

25. Subungual Hematoma Evacuation CPT – 11740 –Evacuation of subungual hematoma

26. Ingrown Toenail (Onychocryptosis) • Common • Leads to pain/ disability • Etiology - ill-fitting shoes, improper toenail cutting, trauma. • Ingrown toenail spicule leads to inflammatory response

27. Stages of Ingrown Toenails • Stage 1 - erythema, pain, swelling • Stage II – erythema, pain, swelling, suppuration • Stage III – granulation tissue, hypertrophy along with stage II characteristics

28. Ingrown Toenail (Onychocryptosis)

29. Ingrown Toenail Management • Stage 1 – Conservative management • Stage 2 – Partial toenail removal • Stage 3 – Partial toenail removal; Consider referral to Podiatrist

30. Partial Nail Removal • Soak in warm H20 prior to procedure • Digital nerve block bilaterally with plain 2% xylocaine or bupivacaine (marcaine) 0.25% • Prep area with betadine • Elevate the nail edge with hemostats or nail elevator • Partial nail removal 2-3 mm with nail splitter or sharp scissors

31. Partial Nail Removal (Cont.) • Remove the wedged section by rotating the separated portion toward the healthy nail • Apply phenol solution (88%) to the nail matrix • Apply topical antibiotic and dressing • Dispense wound care instructions • Recheck as needed, observe for signs of infection • Prevention instructions

32. Ingrown Toenail - Partial Nail Removal English Nail Anvil

33. Ingrown Toenail - Partial Nail Removal CPT – 11730 – Avulsion of nail plate, partial or complete, simple; single

34. Digital Nerve Block

35. Digital Nerve Block ***No CPT exists for digital nerve block; Service included in procedure performed.

36. Abscess

37. Incision and Drainage of Abscess • Abscess – local collection of purulent materiel in a cavity surrounded by inflamed tissue. • produces pain, pressure and tissue damage. • Furuncle (boil) – Starts in hair follicle or sweat gland • Carbuncle – furuncle extends to subcutaneous tissue • Acute paronychia – abscess around nail • Bacteria involved – Mostly S. aureus and other gram+ organisms, MRSA common !!

38. Skin Tension Lines

39. Indications for I & D of Abscess • An abscess must be drained in order to heal • Systemic antibiotics cannot penetrate the abscess • Check to see if the lesion is “fluctuant” • All skin abscesses, furuncle/carbuncle, inflamed epithelial cysts, paronychia with abscess must have I & D for resolution

40. Contraindications/Caution • Facial abscess - CN VII • Caution in area around vital structures such as the eye and neck • Caution in areas overlying nerves and blood vessels

41. Instruments Needed

42. Surgical Blades

43. I & D Procedure • Determine skin tension lines to minimize scarring • Prep skin with antibacterial agent • Inject local anesthesia • Make a 90 degree stab incision with #11 scalpel blade • Apply pressure to expel purulent material • If no purulent material, reassess and try again • Break up loculations with swab, hemostat or curette • +/- Pack with nu-gauze * • Apply dressing

44. I&DProcedure CPT – 10060 - I & D of single or simple abscess

45. I & D Follow-up/Patient Education • Quick shower and change outer dressing • Expect additional drainage • Return visit 1-2 days • Management options at revisit • Remove packing and repack • Remove packing completely • Partially remove packing • Follow-up as needed for resolution • Warm H2O soaks? • Complete healing takes 7-21 days or longer

46. Fingernail/Toenail Paronychia • Infection of the nail fold. • Usually S. aureus if acute; may be Candidaalbicans if chronic (>6 weeks). • Toenail paronychia often associated with ingrown toenail and requires partial toenail removal. • Usually no anesthetic needed. May use ethyl chloride as local anesthesia • Insert #11 blade into area of fluctuance • Apply pressure and drain • Warm H20 soaks until resolved

47. Draining Paronychia CPT – 10060 – I & D of single or simple abscess

48. Punch Biopsy • Fast and easy procedure to obtain a full thickness specimen for pathology. • Indicated for unknown and malignant lesions. • Great for diagnostic purposes for flat lesions. • Useful to remove small, flat nevi. • Usually good cosmetic results • Useful to diagnose inflammatory disease

49. Indications for Punch Biopsy • Diagnosis • Inflammatory skin disease • Skin cancer • Removal • Small nevi • Dermatofibromas - challenging/often better to not remove

50. Contraindications of Punch Biopsy • Less than optimal biopsy technique for SCC and BCC • Must Know Anatomy!!!!!!!!!!!!!! • Facial nerve • Trigeminal nerve • Eyelid • Digits • Areas with little soft tissue – tibia, digits, ulna, etc