I. Indications and Definitions
A. Incision and drainage (I&D) is the definitive treatment method used for patients
with subcutaneous abscesses. An abscess is defined as a collection of purulent material beneath the skin. The overlying skin is swollen, warm, red, and tender
. It is sometimes difficult to distinguish a localized cellulitis from an
abscess unless the overlying skin is fluctuant. The body areas most commonly in volved are listed in below
:Distribution of abscesses by body part
%Buttocks and perirectal area 25
%Head and neck 20
%Extremities 18
%Axilla 16
%Inguinal area 15
%Other 6
:Distribution of abscesses by body part
%Buttocks and perirectal area 25
%Head and neck 20
%Extremities 18
%Axilla 16
%Inguinal area 15
%Other 6
B. Risk factors for abscess formation include summer months, IV drug use, immuno compromise, minor trauma, and poor hygiene
C. Sebaceous cyst. A sebaceous cyst is a small, nontender, subcutaneous fluid-filled
structure. The patient will report the presence of the cyst for a long period of time
but only recent symptoms when it becomes infected. Removing the capsule when
draining an infected sebaceous cyst will prevent recurrence
D. Pilonidal abscess. A pilonidal cyst occurs in the sacrococcygeal area, 5–8 cm
above the anus, when pilosebaceous glands become distended with keratin. In an
acute infection, an abscess may form that requires I&D. In 85% of cases, these ab scesses recur. Definitive surgical excision is usually required
E. Paronychia. This is a common infection of the lateral nail fold
F. Felon. A felon is an infection of the closed compartment of the volar fingertip
G. Perirectal abscess. The most common type is the perianal abscess, which is a tender, fluctuant mass palpated at the anal verge. Perianal abscesses are treated with
I&D by the emergency physician. Other perirectal abscesses, including the intersphincteric, ischiorectal, and supralevator spaces, are best drained by a surgeon
H. Hidradenitis suppurativa. This is a chronic relapsing inflammatory process affecting the apocrine glands in the axilla, inguinal area, or both. Multiple abscesses
can form and eventually lead to draining fistulous tracts that require surgical management. I&D of these abscesses is frequently necessary and performed in the ED
I. Bartholin’s gland abscess. The Bartholin’s glands are paired glands that provide
moisture to the vestibule of the vaginal mucosa. When the opening becomes occluded, either an abscess or a cyst can develop
neck, groin, or popliteal fossa).
(.B Inability to achieve adequate analgesia (consider drainage in the OR
(C. Proximity to important neurovascular structures or tendons (consult surgeon
(for local anesthesia), 18-gauge needle and syringe (if aspirating), 11-blade scalpel,
curved hemostat, and iodoform packing
B. Use 1% lidocaine to anesthetize the area. Be careful not to inject lidocaine into
the abscess cavity itself because this will only increase tension and pain. For larger
abscesses, procedural sedation may be necessary
C. If it is unclear whether an abscess exists, attempt aspiration of pus with a syringe
and an 18-gauge needle
D. Use the 11-blade scalpel to incise the skin. Incision should be at the point of max imal fluctuance and should extend two thirds of the diameter of the abscess cavity
(except when draining Bartholin’s abscesses, where only an incision 0.5–1 cm
should be made)
E. Express pus from the cavity
F. Use a curved hemostat to break loculations and free any remaining pus
G. Pack the wound with iodoform gauze and cover the wound with gauze. When
treating a Bartholin’s gland abscess, a small catheter (Word catheter) is placed in
the opening instead of iodoform. The catheter should remain in place for several
weeks to allow for the development of a fistula for drainage
H. The patient is instructed to follow up in 48 hours to have the packing removed. If
pus is no longer present and symptoms are resolving, the wound is allowed to heal
by secondary intention
source of article USMLE
C. Sebaceous cyst. A sebaceous cyst is a small, nontender, subcutaneous fluid-filled
structure. The patient will report the presence of the cyst for a long period of time
but only recent symptoms when it becomes infected. Removing the capsule when
draining an infected sebaceous cyst will prevent recurrence
D. Pilonidal abscess. A pilonidal cyst occurs in the sacrococcygeal area, 5–8 cm
above the anus, when pilosebaceous glands become distended with keratin. In an
acute infection, an abscess may form that requires I&D. In 85% of cases, these ab scesses recur. Definitive surgical excision is usually required
E. Paronychia. This is a common infection of the lateral nail fold
 |
| Paronychia |
G. Perirectal abscess. The most common type is the perianal abscess, which is a tender, fluctuant mass palpated at the anal verge. Perianal abscesses are treated with
I&D by the emergency physician. Other perirectal abscesses, including the intersphincteric, ischiorectal, and supralevator spaces, are best drained by a surgeon
H. Hidradenitis suppurativa. This is a chronic relapsing inflammatory process affecting the apocrine glands in the axilla, inguinal area, or both. Multiple abscesses
can form and eventually lead to draining fistulous tracts that require surgical management. I&D of these abscesses is frequently necessary and performed in the ED
I. Bartholin’s gland abscess. The Bartholin’s glands are paired glands that provide
moisture to the vestibule of the vaginal mucosa. When the opening becomes occluded, either an abscess or a cyst can develop
II. Contraindications
A. Pulsatile (suggests an aneurysm) or overlying large vessels (anterior triangle ofneck, groin, or popliteal fossa).
(.B Inability to achieve adequate analgesia (consider drainage in the OR
(C. Proximity to important neurovascular structures or tendons (consult surgeon
III. Equipment
Povidone-iodine solution, 1% lidocaine, 27-gauge needle and syringe(for local anesthesia), 18-gauge needle and syringe (if aspirating), 11-blade scalpel,
curved hemostat, and iodoform packing
IV. Procedure
A. Prepare the area with povidone-iodine solutionB. Use 1% lidocaine to anesthetize the area. Be careful not to inject lidocaine into
the abscess cavity itself because this will only increase tension and pain. For larger
abscesses, procedural sedation may be necessary
C. If it is unclear whether an abscess exists, attempt aspiration of pus with a syringe
and an 18-gauge needle
D. Use the 11-blade scalpel to incise the skin. Incision should be at the point of max imal fluctuance and should extend two thirds of the diameter of the abscess cavity
(except when draining Bartholin’s abscesses, where only an incision 0.5–1 cm
should be made)
E. Express pus from the cavity
F. Use a curved hemostat to break loculations and free any remaining pus
G. Pack the wound with iodoform gauze and cover the wound with gauze. When
treating a Bartholin’s gland abscess, a small catheter (Word catheter) is placed in
the opening instead of iodoform. The catheter should remain in place for several
weeks to allow for the development of a fistula for drainage
H. The patient is instructed to follow up in 48 hours to have the packing removed. If
pus is no longer present and symptoms are resolving, the wound is allowed to heal
by secondary intention
VComplications
Bacterial endocarditis scarring neurovascular injurysource of article USMLE
(m)
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