Incision and Drainage in the ED

Authors: Aimee Charnell / Editor: Swagat Mishra / Codes: DC5, SLO6, SLO9, SuC1, SuC5 / Published: 10/05/2022

Before completing my PhD, I was a general surgery registrar. I regularly performed incision and drainage (I&D) procedures in the ED. I have completed shifts in the ED during my Medical Education PhD and was asked to do a teaching session for the ANPs on I&Ds which was well received.  This blog considers how to perform an I&D in the ED and how those familiar with the procedure might set up practical training sessions.

Firstly, you might have read this introduction and thought ‘that’s not my role’ as an ED clinician, and you are right. Under most circumstances, it is not a requirement for ED clinicians to complete I&Ds; however, for some correctly trained individuals, this procedure might be useful, such as in remote EDs and those where surgeons are in different centres. I completed an I&D recently in my ED role which saved a young lad a 12-hour wait for a surgical assessment unit bed. I also used this skill when deployed remotely with the military. Completing a buttock abscess I&D should form part of the SuC1 competency (anorectal abscesses) in the RCEM portfolio too, so that’s a bonus.

I would not recommend doing an I&D if you have not seen one done before; however, they are easy when you know how. It is one of those times in medicine where ‘see one, do one, teach one’, is adequate. Many EDs will have ex-surgeons lurking, so seek them out to observe (and to complete a DOPs).

Patient selection:

Firstly, abscess selection is key. Think appropriate site, such as back, buttock, or thigh. Groin, joint, and peri-anal abscesses should always go to the speciality. Others depend on your experience. Breast abscesses are often drained under ultrasound guidance, so should ideally go to the speciality too, although management of breast abscesses are listed under the RCEM competencies (SuC5). Finger abscesses or paronychias are covered here. 

Size doesn’t matter.  The outside appearance of the abscess can sometimes be deceiving. I once drained a 3cm buttock abscess that contained around 700mls! That is not the norm, though.  Most will only drain a small amount (no more than 10 mls), regardless of size. The biggest factor is whether you are able to make the incision confidently and quickly before the cold spray stops working.

Also, is it ready for an I&D? If it can be popped like a spot and has a punctum, it is ready. If not, it will need antibiotics (these vary between Trusts) and a re-review in 48 hours.

Image 1: Abscess ready for I&D¹

Secondly, think about why does this patient need this procedure?  Is this a sign of an underlying illness?  I always do a capillary blood glucose and check for anything in the history which might suggest diabetes/IBD.  A short history will usually suggest an abscess, and a longer history (and months/years of a lump with no problems) will usually suggest an infected sebaceous cyst.

Thirdly, are they well? These should only be done in ED if the patient is well.  If they have signs of sepsis/underlying pathology, they should be referred to the speciality.

Consent:

Before the procedure, a Consent 1 form should always be completed. This is the biggest time component but essential. A large emphasis should be placed on the need for follow-up with a district nurse and regular pack changes. This can sometimes last for over a month and so careful explanation is key.  Many patients find the follow-up much harder than the initial procedure.

Short term risks include bleeding, infection, damage to local structures, and incomplete drainage. Long term risks include recurrence, scarring, and the need for further procedures (including an operation). Other procedures include regular dressing changes.

The procedure:

Firstly, you need the right equipment. I use cold spray as I find it less painful than local anaesthetic, which just causes more pressure and pain.  Others would argue otherwise, like everything in medicine. The packing ribbon is the hardest thing to find in the ED and might be your limiting factor. Kaltostat or Aquacel are best. You will need ribbon, but the gauze version of these products (not standard gauze) can be cut into a continuous ribbon.

• Gloves and sterile gloves
• Dressing pack
• Betadine
• Cold spray
• Scalpel (one that is pointy, such as an 11/15)
• Lots of gauze
• Plastic forceps
• Sterile water
• Lots of saline-flush syringes (5+ depending on size)
• Waterproof dressing.
• Scissors
• Packing ribbon
• An assistant
• Consider a wound swab

Clean the area with betadine and make a sterile field from the dressing pack. Ask your assistant to spray on lots of cold spray. Quickly make a large incision from end to end, along langer’s lines.  Squeeze out the contents (and consider sending swab). If you use a swab, this can be used to break down the sticky contents (which are called loculations) too. Clean inside using gauze and flushes, ensuring all areas are fully cleaned.  If it is an infected sebaceous cyst (long history before infection), you will need to cut away the wall using forceps and scissors; be gentle as this is painful. Pack fully with packing gauze (Kalsostat/Aquacel) leaving some of the ribbon out of the wound (see image below). The wound should not be further closed, enabling it to heal by secondary intention. After, clean the area then place waterproof dressing.

Image 2 – Abscess post I&D with ribbon left in place before a dressing is applied ²

Ensure you document clearly and consider writing the next steps for the patient (contacting a district nurse within 48 hours). Safety net, advising to return if unwell or if it refills. The patient does not need antibiotics if cleaned well, but I would consider these if complex.

Teaching:

Teaching I&Ds was so much fun. To do this, you need all of the equipment as above (I used cut gauze to replace packing), plus chicken thighs (with skin), skin-coloured gloves, filling (I used hair conditioner), cotton, and pins.

Firstly, I placed the filling into each glove finger. I tied the cotton tight, meaning that the pressure was high. These are your abscesses.

Image 3

Next, I dissected very small holes in the chicken thigh from the bottom and pushed an abscess through lying it close to the skin. I ensured the chicken thigh and skin was tight using pins (Image 4).

Image 4

Before the practical session, we discussed the indications and consent for the procedure. Then, the ACPs did their own I&Ds.

The session received excellent feedback and I have since supervised a trainee completing an I&D in the ED.

Conclusions

Although I&D is not an essential requirement within the ED, it is a useful skill to have and is a fun skill to do and teach. The most difficult elements are usually sourcing the equipment and time (due to consent and finding the equipment) but is a relatively simple skill to do. Please feel free to get in contact if you have any questions about setting up a teaching session for your trainees.

You can now complete our SBA on Incision and abscesses. Please log in to access it.

References

• Image 1 – Five day old Abscess by Amrith Raj. Wikipedia Commons, 2012.
• Image 2 – Abscess Incision and Drainage, a Photographic Tutorial by Jeffrey Keller. Jail Medicine, 2012.