INCISION AND DRAINAGE OF SKIN ABSCESSES

Question 1

What bug is common for skin abscesses?

Answer 1

Usually Staph – learn if MRSA prevalent in your locale

Question 2

1. What is folliculitis?
2. Usually resolves how?
3. Avoid what?
4. Hot tub folliculitis: common bug?

Answer 2

1. Superficial infection of the hair follicles in the epidermis
2. Usually resolve spontaneously – warm compresses
3. Avoid shaving involved areas
4. – pseudomonas aeroginosa
   Avoid continued exposure

Question 3

1. What is a skin abscess?
2. Furuncle (boil)?
3. Carbuncle?

Answer 3

1. SKIN ABSCESS
   collection of pus within dermis and deeper skin tissues
2. FURUNCLE (boil)
   Infection of hair follicle – pus extends thru dermis into subcutaneous tissue
3. CARBUNCLE
   Coalescence of several infected follicle into single mass with several draining sites

Question 4

INDICATIONS FOR I&D
1. Most patients with what should undergo I&D?
Needle aspiration is inadequate

2. If draining spontaneously, may elect to follow with what?
3. May treat with antibiotics for what?
4. Most healthy patients can be done in where?

Answer 4

1. skins abscesses
2. Warm compresses to promote drainage
3. suspected MRSA
4. out-patient setting

Question 5

Reasons why Iand D may be contraindicated? 4

Answer 5

1. Abscess location may mandate drainage by surgeon
2. Abscess types
3. Patient factors
4. Will leave a scar and may recur

Question 6

CONTRAINDICATIONS/CONCERNS
Abscess location may mandate drainage by surgeon
Such as? 6

Answer 6

1. Perirectal area;
2. anterior and lateral neck;
3. breast near areola
4. Near vital nerves or major blood vessels
5. Hand abscesses (excluding paronychia and felons)
6. Central triangle of face (bridge of nose, corners of mouth) may extend intracranially through cavernous sinus)

Question 7

What kind of abscess types would be contraindicated for Iand D?

Answer 7

1. Recurrent and interconnected abscesses

2. Large (> 5 cm), best managed in surgery

Question 8

Patient factors that would contraindicate I and D?

Answer 8

1. Airway issues may preclude sedation

2. Bleeding disorder or anticoagulation

Question 9

Risk factors for abcesses?

DIFFERENTIAL DIAGNOSIS? 4

Answer 9

1. Diabetes mellitus
2. Immunologic abnormalities
3. Breaches of skin barrier

DIFFERENTIAL DIAGNOSIS

1. Folliculitis
2. Parasites
3. Fungal diseases
4. Nontubercular mycobacteria

Question 10

PREPROCEDURE PREPARATION
1. Evaluation of the abcess includes?

2. Medical issues that need to be taken into consideration? 2
3. Patient counseling includes? 5

Answer 10

1. Evaluation of the abscess
   If extent and location uncertain, ultrasound reliable
2. Medical issues
   - Lidocaine allergy
   - Heart valve or total joint, need antibiotic prophylaxis
3. Patient counseling
   - Explain procedure, risk of recurrence, scar formation
   - May need a bigger incision than anticipated
   - Procedure often involves some discomfort
   - Explain after care
   - Will not be totally comfortable in out-patient setting

Question 11

Antibiotic therapy
1. Not necessary for what?

2. Consider when? 6
3. Oral agents when? 4
4. Sick patient with suspected MRSA… ?

Answer 11

1. simple abscesses in healthy patients
2. • abscess > 5 cm,
   • extensive cellulitis,
   • signs systemic infection,
   • comorbidities,
   • immunosuppression,
   • prosthetic joints and valves
3. • clindamycin,
   • doxycycline,
   • doxycycline,
   • smx/tmp
4. parenteral Vancomycin

Question 12

Should we give Tetanus prophylaxis?

Answer 12

Determine patient’s
vaccination status and
provide if indicated

Question 13

SEDATION, ANALGESIA, ANESTHESIA

Lack of pain control hampers adequate I & D: Local anesthesia usually sufficient for most simple abscesses
1. What are your short acting and long acting local anesthetics?

2. Whats more effective than local infiltration?
3. Does not provide what?
4. May be able to do what kind of block?

Answer 13

1. Short and long acting – lidocaine, marcaine
2. Field block more effective than local infiltration
3. Does not provide deep anesthesia
4. May be able to do with regional block (finger or toe)

Question 14

SEDATION, ANALGESIA, ANESTHESIA
Children and those with large abscesses
1. May need what? 3
2. Monitor what? 
3. Have what on hand when giving this? 2

Answer 14

1. May need supplemental sedation,
   - lorazepam and/or
   - IV MS or
   - Dilaudid
2. Monitor respiration,
3. have
   - Narcan (naloxone) and
   - Romazicon (flumazenil) on hand

Question 15

Avoid toxic doses of lidocaine
What are the appropriate doses:
1. Plain lidocaine?
2. Lidocaine with epi?

Answer 15

1. 4mg/kg for plain lidocaine

2. 7 mg/kg for lidocaine with epinephrine

Question 16

EQUIPMENT FOR I & D

12

Answer 16

1. Sterile gloves, drapes, and 4 x 4 inch gauze
2. Goggles or other eye protection (eg, mask with integrated visor)
3. Povidone-iodine solution
4. Local anesthetic (1 or 2 percent lidocaine
5. 3-10 ml syringe with 25, 27 gauge needle
6. Culture swab
7. Number 11 blade and scalpel handle
8. Curved hemostats Forceps Scissors
9. 30 to 60 mL syringe with 19 gauge IV catheter or irrigation device with splash protection
10. Basin with sterile saline solution
11. Packing material (eg, iodoform or plain gauze packing tape)
12. Dressing of choice

Question 17

PROCEDURE – I & D

11

Answer 17

1. Prep and drape wound
2. Establish anesthesia/analgesia
3. Incise skin in line with natural folds of the skin
4. Full length of the incision, avoid cruciate incisions
5. Culture the pus, preferably within the wound
6. Spread wound with hemostat, look for pockets
7. Debride (remove) necrotic tissue
8. Irrigate with isotonic saline until wound is clear
9. Pack or drain wounds with significant dead space
10. Apply dressing
11. Antibiotics: dicloxacillin, cephalosporin (Keflex)

Question 18

MRSA: antibiotics? 3

Answer 18

MRSA?

1. Doxycycline,
2. smx/tmp,
3. clindamycin

Question 19

1. Closure: best left open, especially in:
   (If closed, use what?)
2. Packing or drain – where there is a cavity
   - Why?
   - What kind of gauze?
   - Might want to insert what for drainage?
3. Cover with sterile dressing how?

Answer 19

1. -Immunocompromised,
   -systemic infection,
   -significant cellulitis
   (loose interrupted vertical mattress – may speed healing)
2. • To keep wound from closing, not to plug it
   • Sterile gauze, iodoform gauze, silver-containing hydrofiber
   • Penrose drain or catheter
3. ACE or Tape

Question 20

INSTRUCTIONS AND FOLLOW-UP

1. Specifically about the dressing?
   - Extremity?
2. Seek medical attention if what? 4
3. Wound should be rechecked when?

Answer 20

1. Leave dressing alone and
   - elevate the extremity
2. • Fever or chills
   • Reaccumulation of pus in the area
   • Red streaks
   • Increased swelling
3. 24-48 hours

Question 21

AFTERCARE
Depends on how wound was treated and is responding
1. Resolvig wounds? 2
2. Packing or draining? 2
3. Sutures placed? 2
4. Abscess recurs? 2

Answer 21

1. Resolving wounds
   - Soak in warm, soapy water or shower
   - Protect with dry, sterile dressing until wound is closed
2. Packing or drain
   - Remove when drainage stops and treat as above
   - If drainage persists, repack
3. Sutures placed
   – remove in 7 – 10 days
   - Remove if pus reaccumulates, irrigate and leave open
4. Abscess recurs –
   - repeat I&D,
   - consider referral

Question 22

Complications:
Not common, but more likely in:
3

Answer 22

1. Anterior facial triangle (“the danger triangle”)….increased risk of infection spreading to cavernous sinus
2. Nose and mouth
3. Pilonidal cyst or perirectal area

Question 23

Inadequate drainage may result in local extension

What may you see with this?

Answer 23

May see deep complications (bone & joint infections)

Question 24

Overly aggressive debridement

may damage what causing what?

Answer 24

deep structures or cause a bacteremia