Abscesses
GENERAL CONSIDERATIONS
Cutaneous abscesses requiring drainage are commonly encountered in the emergency department and are best treated with routine incision and drainage. Antibiotic therapy alone is an inadequate treatment strategy. Frequent errors include
Making an inadequate incision for complete initial or continued drainage
Failing to stress the need for 24- to 48-hour follow-up in patients with significant abscesses requiring drain replacement and reassessment
Failing to institute antibiotic treatment or recommend hospital admission in patients with significant cellulitis, systemic evidence of infection, or compromise of the immune system (including diabetes mellitus)
Local cutaneous infection without fluctuance will not benefit from incision and drainage, and this presentation is common. Although local induration and pain with palpation are expected along with other signs of infection, true fluctuance or the perception that free pus is contained within the tissues is not present in this group of patients. These patients should be instructed to apply heat to the area four to six times per day, receive an appropriate antistaphylococcal antibiotic such as dicloxacillin or cephalexin, and be reevaluated in 24 to 48 hours; patients should be told that at that time the abscess may be ready for incision and drainage. Consideration should be given to antibiotic coverage against the emerging community-acquired methicillinresistant Staphylococcus aureus, such as TMP/sulfa, but only if antibiotics are indicated. We have divided our discussion into nonfacial and facial abscesses because of important differences in the approach to these two groups of patients.
NONFACIAL ABSCESS
Our approach to patients with fluctuant, nonfacial abscesses is as follows:
The area overlying and surrounding the abscess is prepared with povidone-iodine (Betadine) and draped in the usual fashion.
Systemic analgesia may be considered, given the poor efficacy of local anesthesia in the acidic medium of the purulent cavity.
Local anesthesia may be provided in a number of ways depending on the size and depth of the abscess and the depth of tissue through which one must incise. Large abscessesRelated posts:
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