Tag Archives: Abscess

Todd Wilcox, New JailMedicine Editor, The Seton I&D Technique

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Hi, my name is Todd R. Wilcox, MD and I want to introduce myself as the incoming editor of jailmedicine.com.  I have followed Dr. Keller’s work and this website since it was first published and I’ve been a big fan of the level of practicality and informative insights he has brought to the practice of medicine in correctional facilities.  I hope to be able to continue that trend and to broaden the input with some additional specialists who see incarcerated patients and manage their unique healthcare needs.  I have worked in correctional healthcare as a physician for 26 years and I am the medical director of the Salt Lake County Jail System in Salt Lake City, UT.  I completed my undergraduate work at Duke University and then attended medical school at Vanderbilt University School of Medicine.  I also have a Masters of Business Administration from the University of Utah. I am board certified in Urgent Care Medicine and my clinical interests include wound care, pain management, orthopedic injuries, and HIV medicine.  I am a frequent lecturer at NCCHC, ACA, AJA, and the National Sheriff’s Association and I look forward to engaging with colleagues who are similarly interested in the challenges of delivering healthcare to our incarcerated patients.  

Skin Abscess Treatment with the Seton Technique

In correctional health settings, we encounter a lot of skin abscesses on various parts of the body. The traditional technique of doing an incision and drainage (I&D) of an abscess has many limitations which has prompted the development of a new technique called a seton placement. This technique originally started with the colorectal surgeons who were treating pilonidal cysts and peri-rectal abscesses and it has been adopted for skin abscesses by the emergency medicine physicians.

A traditional I&D is generally accomplished using lidocaine infiltrated into the skin and into the abscess cavity and then a number 11 or 15 blade is used to open up the entire abscess and squeeze all of the pus out which then creates a cavity that needs to be packed. While this technique is effective and is the traditional treatment for skin abscesses, there are many limitations for using this technique in a correctional setting.

  • it is difficult to anesthetize an abscess due to the acidic nature of the pus that deactivates the local anesthetic
  • I&D technique is generally very painful for the patient
  • I&D tends to be very messy with a lot of pus and blood produced that is often under pressure and squirts all over
  • the wound backings that are necessary to get this wound to heal by secondary intention are painful for the patient
  • the wound packings take a lot of time for the nursing staff
  • the cosmetic result is unfavorable
  • the total treatment time to get a wound to heal by secondary intention is often two weeks or more

The new technique of seton placement was designed to address many of these shortcomings. The technique is described below:

Necessary equipment

  • Local anesthetic.  I generally use 1% lidocaine with epinephrine.
  • 5cc syringe with 18 g and 25-27 g needles
  • Chux pad
  • 4×4’s
  • #11 scalpel
  • Silicone vessel loops (we stock 2 sizes)
  • Noyes alligator forceps
  • Island gauze dressing

The Technique

  1. This technique does not require sterile technique or prepration.  It is a clean technique, not a sterile one. 
  2. The abscess is palpated and the edge of the abscess is identified in two spots 180° opposite each other.
  3. You can use a pen to draw on X at your marked spot.
  4. In identifying the two spots for the incisions it is important to locate one of them at the most dependent area of the abscess so that drainage of the entire abscess will occur.
  5. A wheal of local anesthetic is raised at those two spots
  6. A number 11 blade is then used with the cutting edge facing away from the body to make two small stab incisions at the identified spots and they need to extend into the abscess cavity completely.  This should result in a return of pus and blood as the scalpel is taken out.  It is much easier to shield and divert the pus in this technique compared to a traditional I&D
  7. Once the two incisions are made, a Noyes passer is used to connect the two incisions and the passer goes in one incision, through the middle of the abscess cavity, and then out the other incision.  A Noyes passer is much easier to use and to pass than a hemostat, but you can use a hemostat if needed.  Your incision holes will need to be bigger to accommodate the width of the hemostat. 
  8. The teeth of the Noyes passer are then used to grab the silastic vessel loop and that is pulled back through the abscess cavity.
  9. The silastic vessel loop is then tied in a loose air knot with usually 6 to 8 throws of knots on top.
  10. The tails of the vessel loop are then cut leaving a very loose suture with the silastic vessel loop in the skin.
  11. An island dressing is applied over the top of this and the patient is free to go.
  12. The patient may shower and generally the only dressing necessary for this technique is an island dressing every day for the next few days.
  13. The patient is instructed to grasp the knot and move the silastic loop back and forth once a day to break up any crusting or adhesions to keep the holes open.
  14. The general order for removal is done on day five and a nurse goes and clips the silastic loop with a scissor and removes it just like a suture.
  15. By day five the abscess is generally completely resolved and the overlying skin has adhered back down to the deeper tissue and the treatment for the abscess is resolved at that time.

This technique affords many advantages over the traditional technique:

  • Because you are anesthetizing the very edge of the abscess you are actually anesthetizing normal skin which is much easier to achieve good anesthesia with a local anesthetic than attempting to anesthetize the top of an abscess.
  • Properly done, this technique is almost painless for the patient.
  • From a provider standpoint, this technique is far faster than doing a traditional I&D. In my experience I can do a seton loop placement in about one third the time it would take me to do a traditional I&D.
  • With this technique, the initial rush of pus and blood can be controlled and it is much less messy for everyone and the risk of an exposure is much less. 
  • Because the skin over the top of the abscess cavity remains intact and vascularized, there is no need for this wound to heal by secondary intent. This results in a much faster healing of the abscess.
  • The post technique nursing care is virtually nothing. All you have to do is provide a Band-Aid or an island dressing to put over the top of the seton for five days and the patient can apply that themselves after they shower. Your nurses will thank you profusely for not making them pack a big abscess cavity.
  • Because the skin overlying the abscess is not cut, the cosmetic result from this technique is substantially superior to a traditional I&D.

The preceding description is a basic description of how this technique is done. Once you gain experience there are some advanced hints and tricks that are possible to use with this technique.

  1. I generally do not use a pen to place an X on the skin except in unusual circumstances where the placement of the anesthesia will obscure the edge border. This typically happens on the thicker skin of the face. Generally my technique uses lidocaine with epinephrine and I utilize the placement of the lidocaine with epinephrine to make my mark for me because the vasoconstrictive effects of the epinephrine will make it very obvious where to make your incision.
  2. Most abscesses require the placement of one seton through the abscess. There are occasionally abscesses that have loculations or are large enough that additional setons need to be placed.
  3. I have use this technique with very large abscesses in breast tissue a well as over the deltoid and in those the vessel loops are not large enough to accomplish the drainage. In larger areas I have used sterile tourniquets to place through the abscess cavity as my seton and that has worked beautifully.
  4. For simple abscesses, I have not found antibiotics to be necessary above and beyond the drainage technique for complete resolution of the abscess.  Clearly this is a matter of professional judgment as well as anatomy, and there are certain abscess presentations where supplemental antibiotics would be advisable.  There is some evidence in the emergency medicine literature supporting adjunctive use of anbiotics for some clinical presentations.   

The American College of correctional physicians has a video of this technique on their website.

What technique do you use to I&D abscesses? Please comment!

A Better Way to Drain Abscesses: The Berlin Technique

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One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics.  Jails have always had to deal with skin abscesses.  In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here).  But since the heroin epidemic, the number of skin abscess we see has exploded.  It is not unusual nowadays to lance an abscess every day!

The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses.  And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.

Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”

Who says you can’t teach an old Doc new tricks?  I have wholeheartedly gone over to the Berlin procedure.  It is THE method I use now to drain simple abscesses.

Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses. Continue reading →

Abscess Incision and Drainage, a Photographic Tutorial

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Skin abscesses are quite common in correctional facilities, especially in the MRSA era, and so all correctional practitioners need to be comfortable with the procedure of abscess incision and drainage, also known as “lancing” the abscess.  Also “Let’s cut that sucker open.”  However, I’m going to be professional and call this procedure “I&D” for “Incision and Drainage.”

When I was just starting out in emergency medicine, I&D seemed to be quite a daunting task.  I was afraid of making a mistake and hurting someone or making them worse.  However, in actual fact, I&D is quite easy.  You can potentially hurt people more by not doing an I&D than by doing one.

But, like all medical procedures, it is possible to do the procedure poorly and inefficiently or to make outright mistakes.  The subject of today’s post is how to do a simple I&D of a skin abscess.  The opportunity to take pictures of the procedure arose when a fireman friend of mine walked in to my office and asked me to look at a lump on his back that had been there for a few days.  It was quite sore.  Here is a picture of the lump:

This appears to me to be a MRSA abscess.  Statistically, MRSA causes approximately 75% of all community acquired skin abscesses.  But beyond the statistical likelihood, this looks like a MRSA abscess.  It has lots of pus for its size along with a central area where the lesion is “pointing.”  This appearance is commonly mistaken for a “spider bite” by the lay public.

Why did my friend get a MRSA lesion on his back?  I don’t know.  Why does one member of a family get strep throat but not the others?  It just happens.  Usually, the only way to pinpoint the source is when multiple patients with a common background get MRSA, like members of a wrestling team or inmates housed in the same dorm.  A single, isolated case like this just happens—and not infrequently.

The treatment for MRSA abscess is Incision and Drainage, so I am going to cut this sucker open to let it drain—oops!  I mean I am going to perform an I&D procedure and document the process with pictures and discuss each step.  The process of I&D consists of these steps:

  1.  Skin cleaning.  I did this using alcohol wipes.  It is important to remember that this is not a sterile procedure—even if you do a surgically prep and drape the skin and use sterile gloves, they will not remain sterile once everything is covered by pus from the abscess!  Instead, this is a clean procedure.  You want everything to be clean, but you do not have to perform a formal surgical prep.
  2. Anesthesia.  I prefer to use 0.25% bupivicaine (Marcaine) with epinephrine.  Why Marcaine instead of lidocaine?  Well, they are comparable in price and Marcaine has the advantage of lasting 3-4 times longer, so the area stays numb for 12-16 hours instead of 4 hours.  Why use epinephrine?  The main reason to use epinephrine is that it constricts skin blood vessels so there is much less bleeding.  This makes the procedure that much easier to perform.  Epi also makes the anesthesia last longer—another bonus for the patient!
  3. Make the incision.  I prefer to use a #15 blade scalpel rather than the traditional #11 blade—but either will work.  The most common mistake made when incising an abscess is not to make the incision big enough.  The incision needs to be long enough and deep enough to allow access to the abscess cavity later, when you explore the abscess cavity.  Note that my incision stretches the whole diameter of the abscess—all the way from the top edge of redness to the bottom edge of redness.  Notice also that I have chosen in this case to make the incision run across the lines of tension of the skin by incising from top to bottom.  Typically, you would make an incision run the same direction as the skin creases if you want to minimize the scar.  I don’t care too much about a scar in this case, since the lesion is on the patient’s back.  I am more concerned with adequate drainage of the wound.  By making the incision perpendicular to the creases, the skin will naturally gape open after the procedure and allow pus to drain.  Not allowing the skin edges to touch and potentially re-seal is also the reason for placing packing in the wound, which we will discuss later.
  4. Squeeze out the pus.  This abscess had quite a bit of pus.  By the way, you do not have to routinely send this pus for culture in the majority of young healthy patients, especially if you are not going to prescribe an antibiotic (discussed later).  Culture is a good idea in complicated cases, such as immunocompromised patients, or large complicated abscesses.
  5. Explore the abscess cavity.  There are several reasons to do this.  The first is to see how deep the abscess goes.  Some abscesses are like icebergs—what you see at the surface is only a small portion of the whole abscess.  Some can run amazingly deep.  You should find the full extent of the abscess cavity.  Second, many abscesses have multiple chambers and your incision may have only drained one.  By exploring the cavity, you will break any remaining abscess walls and make sure the entire abscess has drained.  Finally, many abscesses have thick, adherent pus stuck to the walls that does not drain easily.  By rubbing the inner walls of the abscess, you will loosen that thick pus and get it out.  How to explore the abscess cavity depends on the abscess size. I have found that the best instrument for exploring bigger abscess is my gloved finger, as I have done here (as long as you are sure there are no foreign bodies in the abscess).  I have seen surgeons get their whole hand inside really big abscesses (of course abscesses that big probably should be sent to a surgeon).  On the other hand, you may not be able to get your finger into a small abscess.  A curved mosquito forceps with some gauze at the tip works well in those cases.
  6. Irrigate the interior of the abscess with saline.  This is done to make sure that we have all of the pus out.  When the saline draining out of the abscess is clear, the abscess cavity is clean.
  7. Insert a pack.  Abscess packing is perhaps the single most misunderstood aspect of abscess I&D.  The purpose of the packing is to prevent the skin edges from re-sealing.  It is a mistake to think that the packing aids healing.  It does not.  There needs to be enough packing in the interior of the abscess cavity to prevent the wick from falling out, but there is no benefit to stuffing a ton of packing into the abscess.  In fact, that is detrimental, because the packing is a foreign body and because if the packing is packed so tightly so as to exert pressure, it can cause tissue necrosis.  In fact, not every abscess needs to be packed.  If the opening is gaping so widely that there is little chance of the edges re-sealing together, there may be no need for packing.  This point is so important that I will say it again:  abscess packing material is a foreign body.  It can delay healing and resolution of the abscess.  Its only function is to prevent the skin edges from re-sealing. The packing I place today will be removed tomorrow.  I don’t want it in there very long.  It is a foreign body.
  8. Place a dressing.  The first 24 hours after an I&D, the abscess will continue to weep, so it is nice to have an occlusive dressing to prevent he wound from weeping all over clothes and bedding and the inmate’s roommate.
  9. The next day, remove the packing.  Since the packing is a foreign body, it should be removed as quickly as possible.  Notice that this abscess seems reasonably dry after one day.  If the wound were still draining pus, that might mean that I had not fully cleaned out the abscess interior, and I might need to re-explore the abscess to see what I missed.
  10. Leave the abscess open.  Patients at this stage can shower and I encourage them to let the water wash out the interior of the cavity.  Over the next week or two, the abscess will heal in from the bottom out.
  11. Antibiotics? There is a large body of literature that says antibiotics should not be routinely prescribed for MRSA abscesses as long as they can be fully drained and as long as the patient is otherwise healthy and there is no accompanying cellulitis.  This patient is healthy and I see no cellulitis surrounding the abscess, so I am not going to use antibiotics.

This entire procedure took literally about 10 minutes to do.  It turned out well.

ADDENDUM (12/12/12)  This is a picture of the site one week post procedure.  It appears to be healing well.  The skin rash reaction to the dressing tape looks worse than the wound!IMG_0189

Mandatory disclaimer:  The technique I used here is a result of my Emergency Medicine training, my experience and my preferences.  Other practitioners may use other techniques that are just as effective.  Some may even disagree with what I have said here!  You should develop your own technique based on your training, experience and preferences!  A very good official source for the technique of abscess I&D is Roberts: Clinical Procedures in Emergency Medicine, 5th ed.  Chapter 37, Incision and Drainage.  Also, I am talking here about simple abscesses.  Abscesses in complicated areas such as the hands, neck or anus or abscesses of the face where the inevitable procedural scar will be visible may be best sent to a specialist to drain.

Do you have a different technique that you use to I&D abscesses?  Please comment!

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