1. Delwin B. Jacoby, DNP, APRN
Common Office Procedures Baby Health Service Lexington, KY Spalding University Louisville, KY
Delwin B. Jacoby, DNP, APRN

2. Delwin B. Jacoby, MSN, APRN has 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 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 Removal any method of up to 15 tags any area
CPT – – 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. Cryosurgery Techniques CPT – Destruction benign or premalignant lesion by any method, first lesion. CPT – 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 – –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 – – 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&D Procedure
CPT – 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 Candida albicans 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 – – 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

51. Equipment for Punch Biopsy
Punch – 2-8mm. Choose the punch that can completely excise the lesion
< 3mm may not need sutures
> 6mm , best to use an elliptical excision.
Fine, sharp-sharp scissors
Forceps
Needle holder
Suture material
Local anesthesia

52. Punch Biopsy Procedure
Sterile Technique
Choose a punch to remove entire lesion
Local anesthesia 1% lidocaine
Apply tension perpendicular to Kraissel’s lines with hand not performing the punch.
Apply punch completely over the lesion, apply pressure, and rotate through the dermis – expose the subq. Adipose tissue.
Remove the plug, cut with sharp-sharp scissors and send for pathology
Undermine if needed
Close with simple interrupted sutures
Dress and provide follow-up instructions

53. Punch Biopsy CPT – 11100 – Biopsy of skin, subcutaneous
CPT – – Biopsy of each separate or additional lesion.

54. Shave Biopsy Indicated for raised lesion removal
Advantages – minimal time, simple, no suturing, generally good cosmetic results

55. Shave Biopsy Consider for Not indicated for suspected melanoma!!
skin tags
seborrheic keratosis
nevi
actinic keratosis
Not indicated for suspected melanoma!!

56. Shave Biopsy Prep skin Local anesthesia to elevate lesion
Use #15 blade or DermaBlade
Excise the lesion level or minimally depressed in relation to the surrounding skin.
Achieve hemostasis
Pressure
Electrodessication
Topical agents
Aluminum chloride
Monsel’s solution
Silver nitrate
Submit for pathology

57. Shave Biopsy

58. Shave Biopsy - DermaBlade
CPT – Depends on site and size.
11300 – Trunk, arm, leg < 0.6 cm
Trunk, arm, leg 0.6 – 1.0 cm
Many others, see CPT code book.

59. Elliptical Excision Used when lesion is too large for punch
Removes full thickness lesion
Major steps
Planning
Anesthesia
Incision
Undermining
Hemostasis
Closure

60. Planning the Elliptical Excision
Avoid vital structures! Know anatomy!
Know Kraissel’s lines and plan accordingly
Incisional margin 3x diameter of lesion
Anesthesia
Incision with # 15 blade perpendicular to the skin surface through epidermis and dermis
Undermine to allow closure of the incised area

61. Surgical Blades

62. Elliptical Excision
Hemostasis – pressure, electrocautery, local anesthesia with epinephrine if indicated!!!!
Wound closure – vertical mattress, 2 layer closure, single layer closure.
Send specimen for pathology

63. Elliptical Excision
Remember………… Skin tension lines!!!!

64. Elliptical Excision

65. Elliptical Excision CPT – 11400 – Benign excision, TAL. < 0.6 cm
Additional CPT depending on
size and location.

66. Common Office Procedures References
American Heart Association (2007, April 19).  Prevention of Infective Endocarditis: Guidelines From the American Heart Association, by the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease. Circulation 
Buttaravoli, P (2012) Minor Emergencies. Splinters to Fractures, 3rd Edit. Mosby
Blair, RE (2007, March) “Surgical Management of Soft Tissue MRSA Abscesses”, Family Physician News
Mayeaux, EJ (2009)The Essential Guide to Primary Care Procedures. Wolters/Lippincott/Williams &Wilkins
Pfenninger, JL (2011) Procedures for Primary Care, 3rd Edition: Mosby
Trott, AT (2012) Wounds and Lacerations, 4th Edit. Mosby