INCISION AND DRAINAGE OF SKIN ABSCESSES Flashcards
What bug is common for skin abscesses?
Usually Staph – learn if MRSA prevalent in your locale
- What is folliculitis?
- Usually resolves how?
- Avoid what?
- Hot tub folliculitis: common bug?
- Superficial infection of the hair follicles in the epidermis
- Usually resolve spontaneously – warm compresses
- Avoid shaving involved areas
- – pseudomonas aeroginosa
Avoid continued exposure
- What is a skin abscess?
- Furuncle (boil)?
- Carbuncle?
- SKIN ABSCESS
collection of pus within dermis and deeper skin tissues - FURUNCLE (boil)
Infection of hair follicle – pus extends thru dermis into subcutaneous tissue - CARBUNCLE
Coalescence of several infected follicle into single mass with several draining sites
INDICATIONS FOR I&D
1. Most patients with what should undergo I&D?
Needle aspiration is inadequate
- If draining spontaneously, may elect to follow with what?
- May treat with antibiotics for what?
- Most healthy patients can be done in where?
- skins abscesses
- Warm compresses to promote drainage
- suspected MRSA
- out-patient setting
Reasons why Iand D may be contraindicated? 4
- Abscess location may mandate drainage by surgeon
- Abscess types
- Patient factors
- Will leave a scar and may recur
CONTRAINDICATIONS/CONCERNS
Abscess location may mandate drainage by surgeon
Such as? 6
- 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)
What kind of abscess types would be contraindicated for Iand D?
- Recurrent and interconnected abscesses
2. Large (> 5 cm), best managed in surgery
Patient factors that would contraindicate I and D?
- Airway issues may preclude sedation
2. Bleeding disorder or anticoagulation
Risk factors for abcesses?
DIFFERENTIAL DIAGNOSIS? 4
- Diabetes mellitus
- Immunologic abnormalities
- Breaches of skin barrier
DIFFERENTIAL DIAGNOSIS
- Folliculitis
- Parasites
- Fungal diseases
- Nontubercular mycobacteria
PREPROCEDURE PREPARATION
1. Evaluation of the abcess includes?
- Medical issues that need to be taken into consideration? 2
- Patient counseling includes? 5
- Evaluation of the abscess
If extent and location uncertain, ultrasound reliable - Medical issues
- Lidocaine allergy
- Heart valve or total joint, need antibiotic prophylaxis - 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
Antibiotic therapy
1. Not necessary for what?
- Consider when? 6
- Oral agents when? 4
- Sick patient with suspected MRSA… ?
- simple abscesses in healthy patients
- abscess > 5 cm,
- extensive cellulitis,
- signs systemic infection,
- comorbidities,
- immunosuppression,
- prosthetic joints and valves
- clindamycin,
- doxycycline,
- doxycycline,
- smx/tmp
- parenteral Vancomycin
Should we give Tetanus prophylaxis?
Determine patient’s
vaccination status and
provide if indicated
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?
- Whats more effective than local infiltration?
- Does not provide what?
- May be able to do what kind of block?
- Short and long acting – lidocaine, marcaine
- Field block more effective than local infiltration
- Does not provide deep anesthesia
- May be able to do with regional block (finger or toe)
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
- May need supplemental sedation,
- lorazepam and/or
- IV MS or
- Dilaudid - Monitor respiration,
- have
- Narcan (naloxone) and
- Romazicon (flumazenil) on hand
Avoid toxic doses of lidocaine
What are the appropriate doses:
1. Plain lidocaine?
2. Lidocaine with epi?
- 4mg/kg for plain lidocaine
2. 7 mg/kg for lidocaine with epinephrine
EQUIPMENT FOR I & D
12
- Sterile gloves, drapes, and 4 x 4 inch gauze
- Goggles or other eye protection (eg, mask with integrated visor)
- Povidone-iodine solution
- Local anesthetic (1 or 2 percent lidocaine
- 3-10 ml syringe with 25, 27 gauge needle
- Culture swab
- Number 11 blade and scalpel handle
- Curved hemostats Forceps Scissors
- 30 to 60 mL syringe with 19 gauge IV catheter or irrigation device with splash protection
- Basin with sterile saline solution
- Packing material (eg, iodoform or plain gauze packing tape)
- Dressing of choice
PROCEDURE – I & D
11
- Prep and drape wound
- Establish anesthesia/analgesia
- Incise skin in line with natural folds of the skin
- Full length of the incision, avoid cruciate incisions
- Culture the pus, preferably within the wound
- Spread wound with hemostat, look for pockets
- Debride (remove) necrotic tissue
- Irrigate with isotonic saline until wound is clear
- Pack or drain wounds with significant dead space
- Apply dressing
- Antibiotics: dicloxacillin, cephalosporin (Keflex)
MRSA: antibiotics? 3
MRSA?
- Doxycycline,
- smx/tmp,
- clindamycin
- Closure: best left open, especially in:
(If closed, use what?) - Packing or drain – where there is a cavity
- Why?
- What kind of gauze?
- Might want to insert what for drainage? - Cover with sterile dressing how?
- -Immunocompromised,
-systemic infection,
-significant cellulitis
(loose interrupted vertical mattress – may speed healing) - To keep wound from closing, not to plug it
- Sterile gauze, iodoform gauze, silver-containing hydrofiber
- Penrose drain or catheter
- ACE or Tape
INSTRUCTIONS AND FOLLOW-UP
- Specifically about the dressing?
- Extremity? - Seek medical attention if what? 4
- Wound should be rechecked when?
- Leave dressing alone and
- elevate the extremity - Fever or chills
- Reaccumulation of pus in the area
- Red streaks
- Increased swelling
- 24-48 hours
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
- Resolving wounds
- Soak in warm, soapy water or shower
- Protect with dry, sterile dressing until wound is closed - Packing or drain
- Remove when drainage stops and treat 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&D,
- consider referral
Complications:
Not common, but more likely in:
3
- Anterior facial triangle (“the danger triangle”)….increased risk of infection spreading to cavernous sinus
- Nose and mouth
- Pilonidal cyst or perirectal area
Inadequate drainage may result in local extension
What may you see with this?
May see deep complications (bone & joint infections)
Overly aggressive debridement
may damage what causing what?
deep structures or cause a bacteremia
