Cutaneous Abscess Shownotes

What is an abscess?

    Wiki

Natural History

    Most of these are Staph Aureus, MRSA increasing.  
 
Pertinent History

Ask about DM, Liver or Kidney disease, transplant, chronic steroid use, HIV, History of recurrent abscesses .  These are important comorbidities which affect healing.  Though I take issue with unqualified HIV being placed here.  On HAART, CD4 >400 shouldn’t be different than the general population.

Diagnosis

Diagnosis of abscess can sometimes be tricky.  Pain can limit your ability to detect fluctuance and diffuse cellulitis can hide a pocket of pus. Here is a guide to  Ultrasound diagnosis 

Decision to I&D

This is the treatment—-get the pus out.

Here is a study looking at practice variation amount EM providers

 Sedation?

Physician judgement call.  Some locations, large sized abscesses, etc… may not be able to get adequate anesthesia with local.  

Anesthesia

Local abscess roof anesthesia vs. field block

? buffered lidocaine direct injection ?–I could not find any papers looking at this.

warmed lidocaine?

 

I&D technique

Loop Drain Technique

Video 

To pack or not to pack??

  Here is a small RCT.  Showed a difference in rating pain and pain med use.  No difference in healing.  

Post I&D antibiotics?

These guys from Penn did a great review in Annals 2006.  Very in-depth systematic review. 

I’m going to go ahead and say—

  • Healthy patient, minimal to no cellulitis, no abc
  • DM, steroids, uncontrolled HIV, mostly cellulitic—treat for MRSA

Closure?  What the F***?

Here is a great synopsis of some guy’s from Stony Brook and their systematic review of the literature.  Points out some flaws in generalizing this data to our ED practice. Includes link to the original article.

Singer et al from Stony Brook did their own trial on primary closure.  Here is the paper. Thanks Google Foam.  

              -A few words of my own about this study.  

  • Very small–N=56
  • Excludes DM, HIV, chronic steroids
  • Excludes systemic symptoms, >5cm cellulitis
  • Overall underpowered; but definitely makes you think maybe this could work…

 

Summary

            This just goes to show you even a simple condition that you thought you knew how to treat has controversy.  

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