Incision and Drainage Flashcards
Skin abscesses account for how many ER visits?
- 2% are for eval of skin abscesses
- usually staph
- other skin lesions may mimic abscess
What is folliculitis? Tx?
- superficial infection of hair follicles in the epidermis
- hot tub folliculitis: pseudomonas aeroginosa
- avoid shaving involved areas
- usually resolve spontaneously : warm compresses
Diff b/t skin abscess, furuncle and carbuncle?
- skin abscess: collection of pus w/in dermis and deeper skin tissues
- furuncle (boil): infection of hair follicle - pus extends thru dermis into subq tissue
- carbuncle: coalescence of several infected follicles into single mass w/ several drainage sites
What are indications for an I and D?
- most pts w/ skin abscesses should have an I and D done: needle aspiration is inadequate
- if draining spontaneously, may elect to follow: warm compresses to promote drainage
- may tx w/ abx for suspected MRSA
- most healthy pts can be done in outpt setting
CI and concerns for I and D?
abscess location may mandate drainage by surgeon:
- perirectal area; anterior and lateral neck, breast near areola
- near vital nerves or major blood vessels
- hand abscesses (excluding paronychia and felons)
- central triangle of face (bridge of nose, corners of mouth) may extend intracranially through cavernous sinus
- abscess types:
recurrent and interconnected abscesses, large (over 5 cm), best managed in surgery
- pt factors:
airway issues may preclude sedation, bleeding disorder or anticoagulation
- will leave a scar and may recur
RFs for abscesses?
- DM
- immunologic abnormalities
- breaches of skin barrier
DDx for abscesses?
- folliculitus
- parasites
- fungal diseases
- nontubercular mycobacteria
- squamous cell carcinoma
Preprocedure prep b/f I and D?
- eval of abscess: if extent and location uncertain, US reliable
- medical issues: lidocaine allergy (can use injectable benadryl), heart valve or total jt, need abx prophylaxis
- pt counseling:
explain procedure, risk of recurrence, scar formation, may need bigger incision than anticipated, procedure often involves some discomfort, explain after care, will not be totally comfortable in out pt setting, f/u if necessary
Indications for Abx therapy for abscesses? Agents used? What other prophylaxis should be done?
- not necessary for simple abscesses in healthy pts
- consider: larger than 5 cm, extensive cellulitus, signs of systemic infection, comorbidities, immunosuppression, prosthetic jts and valves
- oral agents: clindamycin, doxycycline, smx/tmp
- tetanus prophylaxis: determine pt’s vaccination status and provide if indicated
Sedation, analgesia and anesthesia used in I and D?
- lack of pain control hampers adequate I and D
- local anesthesia is usually sufficient for most simple abscesses:
short and long acting: lidocaine, marcaine, field block more effective than local infiltration, doesn’t provide deep anesthesia, may be able to do w/ regional block (finger or toe) - kids and those w/ large abscesses:
may need supp sedation, lorazepam and/or IV MS or dilaudid, monitor respiration, have narcan and romazicon on hand - avoid toxic doses of lidocaine:
4 mg/kg for plain lidocaine, 7 mg/kg for lidocaine w/ epi
Equipment used for I and D?
- sterile gloves, drapes, 4x4 gauze
- goggles or other eye protection
- providone iodine soln
- local anesthetic (1 or 2% lidocaine)
- 3-10 ml syringe w/ 25, 27 gauge needle
- culture swab
- number 11 blade and scalpel handle
- curved hemostats, forceps, scissors
- 30-60 ml syringe w/ 19 guage IV catheter or irrigation device w/ splash protection
- basin w/ sterile saline soln
- packing material (iodoform or plain gauze packing tape)
- dressing of choice
I and D procedure?
- prep and drape wound
- est anesthesia/analgesia
- incise skin in line w/ natural folds of skin (avoid cruciate incisions)
- culture the pus, preferably w/in the wound
- spread wound w/ hemostat, look for pockets
- debride (remove) necortic tissue
- irrigate w/ isotonic saline until wound is clear
- pack or drain wounds w/ sig dead space
- apply dressing
- abx: dicloxacillin, keflex (if not MRSA)
- if MRSA: doxycycline, smx/tmp, clindamycin
Closure and dressing of abscess after I and D?
- closure: best left open, esp in:
immunocompromised, systemic infection, sig cellulitis, if closed, use loose interrupted vertical mattress: may speed healing - packing or drain: where there is a cavity - to keep wound from closing, not to plug it, sterile gauze, iodoform gauze, silver containing hydrophobia, penrose drain or catheter
- cover w/ sterile dressing - Ace or tape
Instructions and f/u for pt after I and D?
- leave dressing alone and elevate extremity
- seek medical attention if:
fever or chills
reaccum of pus in the area
red streaks
increased swelling - wound should be rechecked in 24-48 hrs
Aftercare involves what?
- depends on how wound was tx and is responding
- resolving wounds: soak in warm, soapy water or shower, protect w/ dry, sterile dressing until wound is closed
- packing or drain: remove when drainage stops and tx as above, if drainage persists, repack
- sutures placed: remove in 7-10 days, remove if pus reaccumulates, irrigate and leave open
- abscess recurs: repeat I and D, consider referral
