Rosen & Barkin's 5-Minute Emergency Medicine Consult (22 page)

• Routine laboratory tests are not typically indicated.
  
• Glucose determination may be useful if:
  
  • Underlying undiagnosed diabetes is a concern
    
  • There is a concern for associated DKA
    
• For febrile patients who appear septic, systemically ill, or have recent IVDU the following labs are indicated:
  
  • Blood cultures
    
  • Lactate
    
  • Renal function
    
  • CK if myositis suspected
    

• Bedside US can be helpful in distinguishing cellulitis from abscess
  
• CT/MRI can be helpful in determining deep tissue involvement
  
• Plain films may reveal gas in tissue planes
  

• Cellulitis
  
• Necrotizing fasciitis
  
• Aneurysm (especially with IV drug abusers)
  
• Cysts
  
• Hematoma
  

TREATMENT

Caution: Septic patients may require rapid transport with IV access and volume resuscitation.

Septic patient:

• Immediate IV access
  
• Oxygen
  
• Crystalloid volume resuscitation
  
• Blood cultures/lactate
  
• Early antibiotic therapy—broad spectrum to include MRSA coverage.
  
• Rapid source control (abscess drainage)
  
• If patient remains hypotensive after volume resuscitation consider:
  
  • Central venous pressure monitoring
    
  • Mixed venous sampling
    

• Incision and drainage are the mainstays of treatment.
  
  • Incision should be deep enough to allow adequate drainage
    
  • Elliptical incision prevent early closure
    
  • Break loculations with gentle exploration
    
  • Irrigate cavity after expressing all pus
    
• Loose packing of abscess cavity when:
  
  • Larger than 5 cm
    
  • Comorbid medical conditions
    
  • HIV
    
  • Diabetes
    
  • Malignancy
    
  • Chronic steroid use
    
  • Immunosuppressed
    
  • Abscess location: face, neck, scalp, hands/feet, perianal, perirectal, genital
    
  • Promote drainage and prevent premature closure
    
• For simple cutaneous abscesses (<5 cm) packing may not be routinely indicated.
  
• Routine antibiotics are not indicated.
  
• Antibiotics are indicated for the following conditions:
  
  • Sepsis/systemic illness
    
  • Facial abscesses drained into the cavernous sinus
    
  • Concurrent cellulitis (see “Medication”)
    
  • Mammalian bites
    
  • Immunocompromised hosts
    
• Perirectal abscess requires treatment in the operating room
  
• Hand infections that may require surgical intervention:
  
  • Deep abscesses
    
  • Fight bite abscesses
    
  • Associated tenosynovitis/deep fascial plane infection
    
• Loop drainage technique:
  
  • Less invasive
    
  • Simplifies wound care
    
  • Procedure:
    
    • Anesthetize locally
      
    • Incision made at outer margin of abscess
      
    • Use a hemostat to break loculations and manually express pus
      
    • Use hemostat to localize distal margin of abscess and use as guide for a second incision
      
    • Grasp silicone vessel loop with hemostat and pull through and then gently tie
      
    • Patient should move loop daily to promote drainage
      
    • No repeat ED visits generally required
      
    • Removal in 7–10 days is painless
      

Incision and drainage are painful procedures that often require procedural sedation and analgesia.

FOLLOW-UP

In accordance with abscess type and severity of infection

• Sepsis/systemic illness
  
• Immunocompromised host with moderate/large cellulitis
  
• Perirectal involvement
  
• Any abscess requiring incision and debridement in the operating room
  

Most patients with uncomplicated abscesses can be treated with incision and drainage and close follow-up.

• Recheck in 24–48 hr for packing removal and wound check.
  
• Warm soaks for 2–3 days after packing removal
  

• Consider CA-MRSA in recurrent abscesses
  
• Pain control is essential during incision and drainage of abscesses
  
• Beware of tenosynovitis and deep fascial space infections
  

• Alison DC, Miller T, Holtom P, et al. Microbiology of upper extremity soft tissue abscesses in injecting drug abusers.
  Clin Orth Related Res
  . 2007;461:9–13.
  
• Buescher ES. Community-acquired methicillin-resistant
  Staphylococcus aureus
  in pediatrics.
  Curr Opin Pediatr
  . 2005;17:67–70.
  
• Hankin A, Everett W. Are antibiotics necessary after incision and drainage of a cutaneous abscess?
  Ann Emerg Med
  . 2007;50:49–51.
  
• Ladd AP, Levy MS, Quilty J. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children.
  J Pediatr Surg
  . 2012:45:1562–1566.
  
• O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary.
  Acad Emerg Med.
  2009;16:470–473.
  
• Tayal V, Hasan N, Norton HJ, et al. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department.
  J Acad Emer Med
  . 2006;13:384–388.
  
• Tsoraides SS, Pearl RH, Stanfill AB, et al. Incision and loop drainage: A minimally invasive technique for subcutaneous abscess management in children.
  J Pediatr Surg
  . 2012;45:606–609.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Bartholin Abscess
  
• Bite, Animal
  
• Cellulitis
  
• CA-MRSA
  
• Hand Infection
  
• Mastitis
  
• Paronychia
  

CODES

• 566 Abscess of anal and rectal regions
  
• 682.9 Cellulitis and abscess of unspecified sites
  
• 685.0 Pilonidal cyst with abscess
  

BASICS