Procedure - Incision and Drainage

 

According to the US NHAMCS 2008 Survey (Table 18) there were about 1.4 million I&Ds done in US EDs last year, making it the 6th most common ED procedure.  Something everyone should know how to do then.

 

 Indications

1. An identifiable abscess (Wikipedia).  Some are easy to identify, others less so.  When in doubt assume there is one. (EM Lit of Note)

 Contraindications

1. Extremely large or deep abscess that are likely to require extensive debridement and are best done in the OR. Particularly true of large perineal abscess.

2. Palmar space abscess - usually require surgical consultation.

3. Nasolabial abscess (in the 'Danger Triangle' - Wikipedia)- risk of septic phlebitis of the cavernous sinus.

4. (Relative) Abscesses near, or overlying, neurovascular structures - peritonsillar abscess, deep groin or antecubital fossa abscess etc.  Localization of fluid collection and/or vascular structures with Ultrasound or aspiration prior to procedure may mitigate this risk.

Pearls & Pitfalls

Topical anaesthetic for I&D in Children (Academic Life in EM)

Local anaesthesia for I&D (Michele Lin of Academic Life in EM via ACEP News)

Packing or No Packing - the evidence points to NO!  BestBET (incomplete), theNNT.

Antibiotics or not? - a recent review in Annals of Emergency Medicine (Ann Emerg Med. 2007 July;50(1):49-51) shows little evidence for benefit of antibiotics (even with MRSA), but questions remain (extensive surrounding cellulitis etc).  EM Lit of Note reviews a more recent article (Ann Emerg Med. 2010 May;55(5):401-7) (still NO).

Minimizing Odors - once more into the breach with Academic Life in EM (be sure to read the comments for more ideas).

 Supplies

Many EDs stock I&D trays, while others use a standard suture tray with the addition of a scalpel.  At a minimum you will need the following:

  • Universal Precautions - gloves, eye protection, mask (optional - gown, cap/hair cover)
  • Skin cleaning solution - Saline, sterile water, Chlorhexidine (0.5% for open wounds, 2% in 70% ethanol - usually only for sterile procedures, which this is definitely not).
  • Local anaesthetic, syringe and needles (18g or blunt to draw LA, 25g or smaller for infiltration).
  • Incontinence pads/ chux/ other disposable absorbent pads.
  • Scalpel - usually a #11 blade (preferably with a safety shield)
  •  Drapes
  •  Hemostat
  •  Scissors
  •  Gauze
  • Packing/Wick material (usually Iodoform gauze tape)
  • Culture Swab
  • Suction and Yankauer suction catheter (see Minimizing Odors above)

How to do an I&D

There are 2 techniques outlined here - the traditional I&D, and the newer LOOP I&D.

Traditional I&D

This video is from Dr L Mellick (Georgia Health Sciences Emergency Department) and shows an I&D of a sebaceous cyst abscess.  The technique is the same  for other abscesses, but cysts also require removal of the capsule (as shown in the video) to prevent recurrence. (Click to go to the video).

The second video of a traditional I&D shows the technique on the dorsum of a finger. (Click to go to the video)

The NEJM featured I&D in their Videos in Clinical Medicine series (N Engl J Med 2007; 357:e20).  This is a good review but requires Login or Subscription to view.

Loop I&D

The Loop I&D technique is newer and should reduce scar appearances.  This video is from the Rob Orman of the ERCAST series and shows one way to perform this procedure (Click to go to the video). 

This is a second example of the Loop technique, a slight variation in technique. (Click to go to the video)

Here is the link to the ERCAST Q&A where Rob answers listeners e-mails about the technique.

Here are a few papers describing the use of the technique in various settings:

Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children (J Ped Surg 2010 Mar; 45(3):606-609).

Minimally invasive technique in treatment of complex, subcutaneous abscesses in children (J Ped Surg 2010 July; 45(7):1562-1566).

Novel Technique for Management of Bartholin Gland Cysts and Abscesses (JEM 2009 May; 36(4):388-390).

 

One more thing

Check out this interesting article that discusses a novel method for creating a akin abscess model:

A skin abscess model for teaching incision and drainage procedures (BMC Med Educ. 2008; 8: 38.)

  

 

 

 

 

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