Incision and drainage

Diagnosis

1. Ultrasound can be helpful
2. Needle aspiration
3. Check: Blood Glucose, IV drug use (XR r/o needle), consider HIV counseling/testing

Differential Diagnosis

Skin and Soft Tissue Infection

• Cellulitis
  • Hand cellulitis
  • Facial cellulitis
  • Orbital cellulitis
• Erysipelas
• Lymphangitis
• Folliculitis
• Hidradenitis suppurativa
• Skin abscess
  • Anorectal abscess
  • Bartholin gland abscess
  • Pilonidal abscess
  • Scrotal abscess
• Necrotizing soft tissue infections
  • Necrotizing fasciitis
  • Necrotizing myositis
  • Necrotizing cellulitis
  • Fournier's gangrene
• Mycobacterium marinum

Look-A-Likes

• Sporotrichosis
• Osteomyelitis
• Deep venous thrombosis
• Pyomyositis
• Purple glove syndrome
• Tuberculosis (tuberculous inflammation of the skin)

Treatment

1. Antibiotics
   1. Give if there is a large cellulitic component or fever, multiple sites, young or advanced age, abscess in area difficult to drain, associated septic phlebitis, and failure with I&D alone
   2. Need to cover staph and strep
   3. Preprocedure abx for pt with high risk cardiac lesions
2. Update Tetanus
3. MRSA decolonization for pts with recurrent skin infections
   1. Nasal mupirocin+chlorhexidine body wash+/-oral anti-MRSA abx for 5-10 days

Incision & Drainage

• Be sure to document if packing was placed in the wound
• Anesthesia should be lidocaine or Marcaine without epinephrine
• Most patients need some pain medicine prior to procedure

Maximum Doses of Anesthetic Agents

Agent	Without Epinephrine	With Epinephrine	Duration	Notes
Lidocaine	5 mg/kg (max 300mg)	7 mg/kg (max 500mg)	30-90 min	1% soln contains 10 mg/ml 2% soln contains 20 mg/ml
Mepivicaine	7 mg/kg	8 mg/kg
Bupivicaine	2.5 mg/kg (max 175mg)	3 mg/kg (max 225mg)	6-8 hr	0.5% soln contains 5 mg/ml May cause cardiac arrest if injected intravascularly Do not buffer with bicarbonate
Ropivacaine	3 mg/kg
Prilocaine	6 mg/kg
Tetracaine	1 mg/kg	1.5 mg/kg	3hrs (10hrs with epi)
Procaine	7 mg/kg	10 mg/kg	30min (90min with epi)

Follow-up

Wound check in 1-2 days and wound care sheet

See Also

• Lidocaine
• Bartholin Gland Abscess

Source

• Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;52:e18-e55
• Singer A, Talan D. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-1047