Incision and Drainage

Indications

Furuncle (Skin Abscess) at least 5 mm in size

Contraindications

Furuncle of central face (risk of septic phlebitis)
1. Infection below bridge of nose and above lip
2. Treat with Antibiotics and warm compresses

Precautions

Avoid incision deeper than floor of lesion
Wear protective eyewear during Incision and Drainage (e.g. Face Mask with eyeshield)
Follow closely and wound culture higher risk patients
1. Diabetes Mellitus
2. Peripheral Vascular Disease
3. Immunocompromised patient
4. Serious underlying comorbid conditions
Surgery Consultation in complicated abscess
1. Extensive, large, deep abscesses
  1. Consider general surgery Consultation to perform in the operating room
2. Cosmetically challenging areas (e.g. face, Breasts, genitalia, hands)
  1. Consider Consultation with general surgery or plastic surgery

Technique
Standard Incision and Drainage

Clean overlying skin with Betadine or Hibiclens
Inject Local Anesthesia in skin overlying Furuncle
1. Use longer acting agents (e.g. Lidocaine with Epinephrine or Bupivacaine) to allow for adequate duration
2. Consider systemic Opioid Analgesics prior to Incision and Drainage
3. Regional blocks or performance in OR or under Procedural Sedation may be required for large deep abscesses
  1. Consider Field Block
4. Most providers use a Field Block over the surface of the abscess
  1. Inject adequate depth to anesthetize the deepest recesses (but not within abscess itself)
  2. Avoid infiltrating abscess (poor efficacy and increases pain)
Incise lesion with number 11 blade
1. Make adequately wide incision to allow access, prevent reclosure and insert packing (if indicated)
2. Needle aspiration may be considered first
  1. May localize the lesion and confirm purulent contents in unclear cases
  2. In small abscesses, needle aspiration may be attempted alone, in place of blade lancing
    1. However, risk of recurrence, and not generally recommended
Culture from within abscess (if indicated)
1. Typical Bacterial cause is MRSA (>70% of cases as of 2014)
2. Primary management is drainage of the abscess (not Antibiotics)
  1. Cultures are unlikely to drive further management if Antibiotics are not used
  2. Consider culture if Antibiotics are administered (see Skin Abscess for Antibiotic indications)
    1. Obtain wound cultures in patients admitted for soft tissue infection
Break up loculations with hemostat (if needed)
Irrigate wound (questionable efficacy)
1. Typically performed with sterile saline via syringe with splash guard
2. Recommended in most guidelines but does not appear to alter course and may be harmful (e.g. spread Bacteria)
  1. Chinnock (2015) Ann Emerg Med [PubMed]
    1. http://www.annemergmed.com/article/S0196-0644(15)01188-9/abstract
Wound packing options
1. Packing is not required in most wounds (see below)
2. Avoid tight packing (painful, Skin Tenting)
3. Insert sterile gauze packing loosely
  1. Non-iodiform 1/4 inch sterile gauze packing
  2. One end of gauze protrudes as wick from incision site
4. Alternative: Penrose drain insertion (Loop Drainage)
  1. See Loop Drainage below
Alternatives to wound packing
1. See Loop Drainage below
2. Consider not packing small extremity abscesses (<5 cm) in immunocompetent patients
  1. Similar outcomes and less pain without packing
  2. O'Malley (2009) Acad Emerg Med 16(5): 470-3 [PubMed]
  3. Kessler (2012) Pediatr Emerg Care 28(6): 514-7 [PubMed]
3. Consider primary loose closure after Incision and Drainage of small abscesses (<5 cm)
  1. Requires careful drainage of all pockets and well irrigated (studies were done in OR)
  2. Loose closure was performed to allow for possible drainage
  3. Results in more rapid healing and return to work
  4. Consider sewing a penrose drain into the wound and removing the drain after several days
  5. Same abscess recurrence rates (30%) for closure versus no closure
  6. Singer (2011) Am J Emerg Med 29(4): 361-6 [PubMed]
  7. Singer (2013) Acad Emerg Med 20(1): 27-32 [PubMed]
Bandaging
1. Apply sterile dressing over incision

Technique
Loop Drainage (penrose drain insertion via 2 incisions)

Approach
1. Prepare the Incision and Drainage site as above
  1. Clean overlying skin with Betadine or Hibiclens
  2. Inject Local Anesthesia in skin overlying Furuncle
2. Two small, 5 mm incisions made into abscess (each within 4 cm of the other)
  1. First incision at the most fluctuant area of the lesion
  2. Break up loculations
3. Penrose drain inserted into one incision and looped out through the other
  1. Finger of glove could also be used in place of penrose drain
4. Penrose tied loosely on skin surface with 5 to 6 knots
  1. Consider tying penrose over the top of a 30 cc syringe layed flat to allow adrequate slack
5. Patient regularly pulls the loop in alternate directions to maintain open wound drainage
6. Loop is removed in several days by a provider on wound recheck (or in some cases by the patient)
Efficacy
1. Lower failure rates than standard Incision and Drainage
References
1. Roberts (2013) Emerg Med News 5(2): 16-18
2. Gottlieb (2018) Am J Emerg Med 36(1): 128-33 +PMID:28917436 [PubMed]
3. Ladde (2015) Am J Emerg Med 33(2): 271-6 [PubMed]
4. Schecter-Perkins (2020) Acad Emerg Med +PMID:32406569 [PubMed]
5. Tsoriades (2010) J Pediatr Surg 45(3): 606-9 [PubMed]

Disposition
Post-procedure instruction

Wound re-packing is no longer recommended
1. Previously repacking was recommended every 1-2 days
Treat associated Cellulitis if present
1. Antibiotics are usually not needed unless Cellulitis is also present

References

Chan (2014) Crit Dec Emerg Med 28(9): 2-7
Derksen in Pfenninger (1994) Procedures, p. 50-3
Anora and Menchine in Herbert (2014) EM:Rap 14(3): 1-2
Mason, Schmitz, and Gottlieb in Herbert (2017) EM:Rap 18(1): 11-2
Stulberg (2002) Am Fam Physician 66(1):119-24 [PubMed]