Incision and Drainage



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Incision and Drainage

Clean the area with providone-iodine or chlorhexidine.

Consult surgeon or other advanced provider

Determine optimal I&D technique

Consider culture for specific populations

Loosely pack abscess cavity to wound margins with sterile gauze, iodoform gauze, or silver-containing hydrofiber leaving 1 cm wick

Contraindications to epinephrine?

Inclusion Criteria
  • Skin abscess
Exclusion Criteria
  • Toxic appearance
  • Mycotic abscesses
  • Recurrent or extremely large abscess that would require the operating room
  • Complex medical problems related to drainage or sedation
  • Complex anatomical location (Breast abscess, perirectal abscess, Hand abscess, neck abscess likely involving a congenital cyst (thyroglossal, brachial, etc.), abscess in central triangle of face, other complex area (near vital artery, vein or other structure))

Risk for foreign body?

X-ray to identify radiopaque materials

Abscess >5 cm, Pilonidal abscess, Immunocompromised, diabetic?

Warm water soaks 3 times a day until healed

Will this abscess require incision and drainage?

Will abx be beneficial?

Contraindications to probiotics?

Probiotics

Endocarditis prophylaxis?

Will patient need tetanus prophylaxis?

Wound checks every 2 days with packing removal when purulent drainage stops

Warm compresses 4 times a day, follow up with PMD

Patient to require sedation?

Patient to benefit from regional nerve block?

Perform regional nerve block

Tetanus, diphtheria, acellular pertussis vaccine (TDaP) injection

Diet NPO

1% lidocaine with epinephrine field block

1% lidocaine field block

Will patient benefit from antibiotics?

Contraindications to probiotics?

Probiotics

Probe the wound to release loculations and irrigate with copious amounts of tap water

Incision I&D

  • Incise wound using 11 blade scalpel along the skin tension lines to the length of the abscess

Vancomycin injection

Clindamycin or TMP-SMX + Cephalexin

Clindamycin suspension
Trimethoprim-sulfamethoxazole suspension
Cephalexin suspension

Loop I&D

  • Make small (5 mm) stab incision with 11 blade scalpel at one end of the abscess
  • Insert hemostat, break up loculations, tent the skin on the opposite side of the abscess
  • Make a small incision and push the hemostat through the skin
  • Grasp a vessel loop with the hemostat, pull it through to the other side and tie a loose knot
  • Patient to slide loop back-and-forth twice a day and apply warm compresses
  • Remove loop 7-10 days later

Clindamycin or TMP-SMX + Cephalexin

Cephalexin suspension
Clindamycin suspension
Trimethoprim-sulfamethoxazole suspension

Contraindications to lidocaine with epinephrine

  • Peripheral vascular disease
  • History of hypersensitivity to local anesthetics of the amide type
  • Patient with disease process that make them susceptible to epinephrine (HTN, CV disease, etc.)
  • Dirty or contaminated wounds