Incision and Drainage of Abscess

97
Nicholas D. Caputo, Karlene Hosford,
and Muhammad Waseem

97.1 Indications Coagulopathy

Recurrent pilonidal cysts (may mandate operative
Abscess greater than 5 mm in diameter and in accessible excision)
areas (e.g., axilla, extremities, trunk) Area of cosmetic importance where aspiration may be
preferred

97.2 Contraindications
97.3 Materials and Medications
Absolute
Absence of fluctuation Incision and drainage tray (Fig. 97.1)
Large, deep, and complicated (multiloculated) Drape
abscesses Betadine (povidone-iodine) swabs
Location 1 % lidocaine
Perianal 18- and 27-gauge needles
Mastoid 12-mL syringes, gauze pads
Relative #11 scalpel, mosquito clamps (hemostat)
Location Iodoform packing of appropriate size
Face (e.g., nose, nasolabial fold) Ultrasound machine (Fig. 97.2)
Palms

N.D. Caputo, MD, MSc

Emergency Department Critical Care, Lincoln Medical and Mental
Health Center, New York, NY, USA
e-mail: Ncaputo.md@gmail.com
K. Hosford, MD M. Waseem, MD (*)
Department of Emergency Medicine, Lincoln Medical and Mental
Health Center, New York, NY, USA
e-mail: krlhos@aol.com; waseemm2001@hotmail.com

Springer Science+Business Media New York 2016 561

L. Ganti (ed.), Atlas of Emergency Medicine Procedures, DOI 10.1007/978-1-4939-2507-0_97
562 N.D. Caputo et al.

Fig. 97.1 Supplies necessary for

incision and drainage

Fig. 97.2 Bedside SonoSite ultrasound

97 Incision and Drainage of Abscess
97.4 Procedure
1. Ultrasound (optional) may be helpful when abscess is
suspected in the absence of fluctuation. Using the vascu-
lar probe (7 mHz), confirm the clinical suspicion of
abscess and check the depth and width of the abscess
(Fig. 97.3).
2. Sterile skin preparation with Betadine swab and sterile
drape.
3. Anesthetize the appropriate area subcutaneously with
5 mL of 1 % lidocaine by inserting the 27-gauge needle at
an acute angle into the intradermal space (Fig. 97.4a, b).
4. Using a #11 blade, make an approximately 1- to 2-cm
skin incision over the desired area parallel to the Langer
lines. The incision must approach into the abscess cavity
(Fig. 97.4c).
Some physicians still advocate the technique of mak-
ing a cruciate incision. This may leave a larger scar
and should be discussed with patient before doing so
because of cosmetic consequences.
a b
Fig. 97.3 (a) Example of an abscess as viewed on bedside ultrasound. (b) A multiloculated abscess
563
5. Allow for spontaneous drainage. After resolution of
drainage, you may express more pus with gentle down-
ward pressure.
6. Using the hemostat, enter the incision to break any sus-
pected loculations. This should be done with the clamps
closed and curved part down. The clamps should then be
opened and removed slowly (Fig. 97.4d).
7. After clearing the remaining loculations, the wound
should be packed.
Evidence suggests that packing the abscesses
does not prevent recurrence; however, this is still
practiced. If packing the wound, follow the next
step.
8. Take the iodoform packing with the hemostat, and place
the packing into the incision site until no further packing
will fit.
9. Cut the packing leaving a tail out of the incision site
(Fig. 97.4e).
10. Apply dressing with 4 4 gauze and adhesive tape
(2 in.).
564 N.D. Caputo et al.

a c

b d

Fig. 97.4 (a) Abscess with overlying erythema. (b) Lidocaine injection in the superficial layer. (c) Linear incision with #11 blade. (d) Expression
of purulent material and breaking of loculations with clamps. (e) Optional placement of packing
97 Incision and Drainage of Abscess
97.5 Complications
Recurrence of abscess
Progression of cellulitis
Neurovascular injury to adjacent structures
97.6 Pearls
Antibiotic coverage is a controversial topic. Methicillin-
resistant Staphylococcus aureus (MRSA) is a concern not
only in the immunocompromised and diabetic patients. S.
aureus has been detected in up to 51 % of patients with
abscesses. Of these isolates, approximately 75 % were
MRSA. Bactrim (trimethoprim/sulfamethoxazole) should be
utilized for all prophylactic measures.
565
Selected Reading
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Med. 1988;5:2005.
Burney RE. Incision and drainage procedures: soft tissue abscesses in the
emergency service. Emerg Med Clin North Am. 1986;4:52742.
Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled
trial of antibiotics in the management of community-acquired skin
abscesses in the pediatric patient. Ann Emerg Med. 2010;55:4017.
Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath
M. Abscess incision and drainage. N Engl J Med. 2007;357:e20.
Frazee BW, Lynn J, Charlebois ED, Lambert L, Lowery D, Perdreau-
Remington F. High prevalence of methicillin-resistant
Staphylococcus aureus in emergency department skin and soft tis-
sue infections. Ann Emerg Med. 2005;45:31120.
Hankin A, Everett WW. Are antibiotics necessary after incision and
drainage of a cutaneous abscess? Ann Emerg Med. 2007;50:4951.
OMalley GF, Dominici P, Giraldo P, et al. Routine packing of simple
cutaneous abscesses is painful and probably unnecessary. Acad
Emerg Med. 2009;16:4703.