Abscess Management Precautions and Suggestions

1. Abscess Management Precautions and Suggestions Joe Lewis, M.D.

2. Precautions • Where to cut with care: • In general cut with care: Face, Belly, Neck, Near joint lines, near nerves or blood vessels.

3. Special Tips • Face: Avoid incisions due to cosmetic concerns. Needle Aspiration preferable due to cosmetic concerns. Avoid deep incisions due to risk of damaging the facial nerve and causing permanent paralysis and facial deformity. Especially avoid the area demarcated by a line draw from the ear to the corner of the mouth to avoid the branch of the facial nerve which is especially superficial.

4. Special Tips • Belly: Risk of going into abdomen, causing peritonitis and putting the patient into the hospital for open abdominal surgical procedure and long hospitalization. Be very careful to stay superficial. • Neck: risk of hitting carotids and having the patient bleed to death or stroke out. Or the jugular and have significant bleeding.

5. Special Tips • Joint lines: risk of going into joint and causing joint infection, which requires surgery and hospitalization. • Nerves and peripheral blood vessels: Risky locations like ventral surface of wrist, antecubital area, axilla, back of knee, groin, top of foot near big toe or medial ankle. All the areas where you can get a pulse and a lot of nerves go from trunk to an extremity.

6. The branch between the ear and cheek is the most superficial and vulnerable during incision and drainage

7. Another picture of facial nerve and facial nerve paralysis.

8. Facial Nerve Injury

9. Neck blood vessels Don’t cut the throat of your fellow soldiers (or their dependents)

10. Neck blood vessels Don’t cut the throat of your fellow soldiers (or their dependents)

11. Antecubital fossa has veins, arteries and nerves which you don’t want to damage during an I&D

12. Wrist anatomy

13. Deformities from Nerve damage in the wrist and antecubital fossa

14. Deformities from Nerve damage in the wrist and antecubital fossa

15. Avoid Groin Blood Vessels and Nerves

16. General Suggestions • Analgesia is vital: lidocaine +/- narcotic, if it looks real painful and the patient has a ride home, ask the provider about pain shot. • Packing- Ideally just enough to keep it open, you don’t have to pack every cubic millimeter of the cavity.

17. Dressing changes and repacking • How much? - Remember the goal of each repack is to pack with about half or less. -Remember the repack just needs to keep the hole open, not the whole cavity. - Remember the ultimate goal is for the abscess cavity to close.

18. Dressing changes and repacking How many times? • Ideally less then 4-5 times. • This hurts, so work towards reducing the number of repacks.

19. Dressing changes and repacking • Analgesia or Pain Medicine? • Yes. • It hurts. • Be humane. • Don’t be a torturer !