1. Incision and Drainage
  2. Pap Smear
  3. Laceration Repair
  4. Cauterization
  5. Toenail Removal

    Treatment of onychocryptosis (ingrown nail)

    avoid lidocaine with epinephrine in digits due to vasoconstriction. 

    use lidocaine 1% to numb.  onset of action is 2-5 min and duration is 30-60. 

    Dr. Tuten added bupivacaine (1:1 ratio) to his syringe due to the longer half life. bupivacaine takes 8-12 min to start working. 

    Lidocaine 1% without epinephrine
    10ml syringe
    1 to 1.5 in, 25 to 27 g needle
    betadine swabs
    sterile drape
    suture kit with hemostat and scissors
    sterile gauze 
    tubular gauze dressing
    abx ointment

    -pt. in supine position
    -scrub digit with betadine
    -you will numb the digit first before preparing sterile field.  You will need to let sit for 20 min to get completely numb.  
    -may need assistance with betadine and anesthetic 
    -withdraw 5 ml of lidocaine
    -inject in a ring fashion around the toe.  initial injection should be proximal to the edges of the medial nail fold on the dorsal surface of the toe. Four digital nerves should be anesthetized: both extensor and plantar branches of the medial and lateral nerves. 
    - inject 1 ml of anesthetic around each nerve site starting dorsally and directing the needle gently in a plantar direction, injecting around the plantar digital nerve.  
    -repeat on the lateral side of the toe. 
    -let toe numb for 20 min.

    -prepare sterile field, add extra gauze, needles, etc.
    -cut 1/3rd of toenail lengthwise with sterile scissors. (if removing entire nail, cut in half)
    -loosen and lift the nail with a narrow periosteal elevator.  separate the nail from the underlying nail bed. 
    -silver nitrate can be used to control bleeding.  or hold pressure with gauze. 

    -apply abx ointment
    -apply a sterile, nonadherant gauze pad to site. 
    -wrap toe with tubular gauze. 
    -pt. to wear a hard-soled shoe

    keep foot elevated
    OTC analgesics are sufficient
    change dressing 24 hrs. 
    soak toe in warm water bid
    watch for s/s infection
    trim toenail in flat, straight across fashion
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