The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Incision & Drainage

by Ashley Stuckey

Indications
Prerequisites
Equipment
Procedure
Complications
Follow-up
References

Indications

• Abscesses often appear as fluctuant and tender masses in dermal or subdermal tissue. Inflammatory characteristics that include heat, pain, swelling, and redness will be obvious.
  
• Early presenting abscesses with minimal fluctuation should be aspirated to differentiate from cellulitis. Cellulitis should be treated only with antibiotics, elevation', and immobilization. However, incision and drainage should be performed on any abscess with signs of pus.
  
• Contraindications to drainage in the Emergency Department include deep foreign bodies, pulsatile masses, or infections that are proximal to important vascular or nervous structures.
  
• Soft tissue infections with extreme pain or deep involvement should be considered surgical emergencies since necrotizing fascitis and myonecrosis are possible.
  
• Patients with human bites to the hand and infected hand wounds should be considered for admission.
  
• Perirectal or periurethral abcesses should not be drained in the Emergency Department. Perirectal abscesses often have deeper involvement than appears on physical exam and should be considered for surgical treatment. Perianal abscesses with superficial fluctuation not associated with other perirectal infections can be incised in the Emergency Department.
  
• Abscesses involving the "danger area of the face" that drain into the cavernous sinus should involve an otorhinolaryngologist or ophthalmologist.

Prerequisites

• In the healthy patient, no labs or cultures are required.
  
• If the wound involves trauma, drug abuse, or the suspicion of deep infection exists, x-rays should be ordered.
  
• Ultrasound is beneficial for nonradiopaque foreign bodies.
  
• Immunocompromised patients should have a blood count taken and labs for diabetic patients should include electrolytes, BUN, creatine, glucose, and urinalysis.
  
• Fever, indicating systemic involvement, edema, severe pain, or toxic-like qualities require cultures of the abscess.

Equipment

• Scalpel and blades
  
• Mayo forceps
  
• Scissors
  
• Suction (to drain larger abscesses)
• Saline
  
• Gauze sponges or Iodoform gauze

Procedure

1. Nitrous oxide or IV anesthesia/sedation (morphine, midazolam, meperidine, or fentanyl) should be given and is usually more effective than local anesthesia. Benzodiazapines are optional to relax the patient. Depending on the location, size, and innervation of the wound; regional, Bier, or field blocks can be used.
   
2. In high-risk patients that are septic or
   immunocompromised, parenteral antibiotics (ist generation cephalosporin) should be given one hour before incision and drainage.
   
3. The skin should be washed with iodine and then the patient and field draped.
   
4. Incise the abscess along the superficial skin creases across the entire fluctuant area with a #1 I blade scalpel for small abscesses and a #15 or #10 for larger abscesses. For larger abscesses, it may be helpful to elliptically incise along the roof of the abscess to gain better entry to the cavity.
   
5. Remove any necrotic or devascularized tissue with scissors. Smaller cavities can be probed with forceps to break up loculations while larger cavities respond well to a finger covered with gauze.
   
6. Low-pressure irrigation with a bulb syringe should be used on clean wounds. High-pressure irrigation with a 18 gauge IV catheter and a 35ml syringe of 250ml-IL of saline for dirty or contaminated areas is necessary. Hold the catheter, fastened to the saline-filled syringe, perpendicular to the wound and evacuate the contents of the syringe in a pulsatile manner.
   
7. Loosely pack the cavity with iodoforin gauze as overpacking will inhibit proper healing. This is not a contest to see how much you can pack into the cavity. Simply filling the space is sufficient. Packing will continue the drainage and prevent the wound edges from closing too early.
   
8. Apply an absorbent dressing.
   
9. Instruct the patient to apply warrn compresses to aid the drainage.
   
10. No outpatient antibiotic therapy is recommended in the healthy patient unless significant signs of cellulitis are present.
    
11. Antibiotic prophylaxis is recommended in the following situations:
    • immunocompromised and diabetic patients
    • patients with a history of peripheral vascular disease
      
    • patients with highly contaminated wounds, or
      cellulitis

Complications

• Respiratory depression and vital signs must always be assessed with the use of anesthesia.
  
• Splashing and contamination of the health-care provider can be prevented with the appropriate use of gloves,
  goggles, and mask.
  
• Incision and drainage complications involving systemic infection need to be guarded against. Patients who are immunocompromised and those with diabetes mellitus should to be given special attention regarding antibiotic treatment and hospital admission to combat infection.
  
• Abscesses involving trauma or foreign bodies are often present in drug-users so other risks (Hepatitis, HIV) should be considered.

Follow-Up

• Follow-up should occur in 24-48 hours to remove the packing and assess the progress of healing.
  
• If significant drainage persists, repack the cavity.
  
• If drainage is decreased, have the patient soak the wound with warm water 3 to 4 times a day.
  
• Keep the wound covered at all other times.
  
• Healing should take 5-9 days.

References

1. Allison, E. Jackson, Jr. and John Gough. "Cutaneous Abscesses." Emergency Medicine-A Comprehensive Study Guide. New York: McGraw Hill, 1996.
   
2. Connell, Patrick and John 1. Ellis. "Cutaneous Abscesses and Gas Gangrene." Principles and Practice of EmerR-ency Medicine. 3rd ed. Philadelphia: Lea & Febiger, 1992.