When is an abscess ready to drain

The patient should be instructed to return to the ER sooner for worsening pain, swelling, erythema or for signs of systemic illness such as a fever, vomiting and myalgias.

It is often curative and antibiotics are rarely indicated. Patients should be instructed on home care and the importance of a recheck in approximately 2 days. Introduction What may begin as a localized superficial cellulitis after a compromise of the epithelium can result in an abscess. Indications Diagnosis of abscess is often made by observation of a tender, erythematous, warm, fluctuant mass on physical examination such as that noted in Figure 1.

Figure 1: Abscess in an African American patient Because there may be surrounding cellulitis, induration can make an abscess less apparent on physical exam. Figure 2: Ultrasound image demonstrating cobblestoning often seen in cellulitis Figure 3: Ultrasound image demonstrating fluid collection consistent with abscess If there is a localized area of induration but no fluctuance on exam or fluid collection on ultrasound, home care with application of heat via warm compresses or soaks along with antibiotics may be attempted.

Incision and Drainage Make a linear incision across the diameter of the fluctuant area, ensuring appropriate depth to have reached the cavity of purulence as in Figure 4 and 5. Figure 4 and 5: Incision, drainage and use of hemostats to break up loculations Normal saline is often used via a syringe which may have an attached angiocatheter or splash-shield to irrigate the cavity, though current evidence makes this is of questionable benefit.

Chapter 37 Incision and Drainage. Academic Emergency Medicine ; Emergency Medicine Procedures. Chapter Subcutaneous Abscess Incision and Drainage. New England Journal of Medicine. It forms when the body tries to protect itself from an infection by creating a wall around it. The pus contains bacteria, white blood cells, and dead skin. Most people carry these bacteria on their skin yet never develop an infection.

However, when the bacteria penetrate the skin through a cut, along a hair follicle, or under the edges of a wound , they may lead to an abscess. A skin abscess is round and feels firm and squishy due to the thick membrane around it and the liquid pus inside. It is usually painful, and the overlying skin is often red. Sometimes there is a pinpoint opening in the center a punctum.

This is the weakest part of the wall and pus might spontaneously drain through it. The only certain way to treat an abscess is to open the pocket and drain the pus. A surgical knife is used to cut a hole in the wall of the abscess and empty it of pus.

Sometimes the doctor will pack the wound or leave a wick , which means stuffing the empty pocket with a ribbon of gauze. This allows the pus to continue draining and prevents the abscess from returning. Your doctor will instruct you to gently pull out a small part of the wick every day until it all comes out. Eventually, the entire gauze will be removed and the wound will heal from inside out. If the cavity is large, you may be asked to come back to the office so the gauze can be replaced entirely.

Warm, moist compresses or baths are also recommended to keep the wound open and draining. Splint the affected part if possible, particularly if a joint is affected. Reevaluate and redress the wound in 24 to 48 hours. Exceptions are some small abscesses, such as paronychias or small furuncles, which do not need to be monitored as closely. Instruct the patient to elevate the wound and not disturb the dressing and splint before the first follow-up visit.

Any packing may be removed once there is healthy granulation tissue throughout the cavity and there is no longer any drainage.

Have the patient begin warm soaks and gentle hydrostatic debridement at home ask the patient to hold the skin incision open and direct the shower or faucet spray into the abscess cavity. Continue dressing changes every 1 to 2 days and follow-up visits as needed until fully healed.

Patients should be reevaluated if they have worsening pain, increased drainage, or spreading erythema. Prescribe empiric antibiotic therapy after drainage with a drug active against methicillin-resistant Staphyloccocal aureus Staphylococcal Infections Staphylococci are gram-positive aerobic organisms.

Staphylococcus aureus is the most pathogenic; it typically causes skin infections and sometimes pneumonia, endocarditis, and osteomyelitis High-risk heart disease High-risk patients Infective endocarditis is infection of the endocardium, usually with bacteria commonly, streptococci or staphylococci or fungi. Immunocompromised patients should receive antibiotics for at least 5 to 7 days after the procedure. A common practice is to give an initial IV dose of antibiotic in the emergency department, followed by oral antibiotics.

The skin of a pointing abscess is very thin, making it difficult to inject local anesthetic into the skin rather than the abscess cavity; use a field block instead.

Incising skin before pus localizes into an abscess is not curative and may even extend the infectious process. If it is unclear whether pus is present, do ultrasonography or have the patient apply heat and take antibiotics and analgesics eg, NSAIDs, acetaminophen and reevaluate in 24 to 48 hours. Without proper incision and drainage, spontaneous rupture and drainage may occur, sometimes leading to the formation of chronic draining sinuses.

Incomplete resorption may leave a cystic loculation within a fibrous wall that may become calcified. Perirectal abscesses Treatment An anorectal abscess is a localized collection of pus in the perirectal spaces.

Abscesses usually originate in an anal crypt. Symptoms are pain and swelling. Diagnosis is primarily by examination Patients with large and deep abscesses should be admitted to the hospital for evaluation and treatment under general or spinal anesthesia.

A facial abscess above the upper lip and below the brow may drain into the cavernous sinus, so manipulation of an abscess in this area may predispose to septic thrombophlebitis. After incision and drainage, treat with antistaphylococcal antibiotics and warm soaks and have frequent follow-up visits.

Some small skin abscesses may drain naturally and get better without the need for treatment. Applying heat in the form of a warm compress, such as a warm flannel, may help reduce any swelling and speed up healing. However, the flannel should be thoroughly washed afterwards and not used by other people, to avoid spreading the infection.

For larger or persistent skin abscesses, your GP may prescribe a course of antibiotics to help clear the infection and prevent it from spreading. Sometimes, especially with recurrent infections, you may need to wash off all the bacteria from your body to prevent re-infection decolonisation.

This can be done using antiseptic soap for most of your body and an antibiotic cream for the inside of your nose. However, antibiotics alone may not be enough to clear a skin abscess, and the pus may need to be drained to clear the infection. If a skin abscess is not drained, it may continue to grow and fill with pus until it bursts, which can be painful and can cause the infection to spread or come back. If your skin abscess needs draining, you'll probably have a small operation carried out under anaesthetic — usually a local anaesthetic , where you remain awake and the area around the abscess is numbed.