I don’t know about where you work but if a patient comes in with an abscess too big to do under local (the wonderfully ineffectual local…) then they get admitted under the surgeons to get it done under GA. Obviously this can then involve up to a couple of days wait for a slot on the emergency list in theatre.
Think about that for a minute. We have a huge shortage of expensive hospital beds and we’re getting pressure to manage every potentially life-threatening diagnosis on an out-patient basis yet when we have a usually well, usually young patient who needs a knife in an abscess they get admitted.
It took listening to Scott Weingart’s excellent series on procedural sedation for the “well d’uh” moment to hit me – why the flip are we admitting these people? This seems like a really easy way to make a few less admissions.
We do a fair number of sedations, largely for orthopaedic stuff, but also for wounds in kiddies. The problem is not the procedure, from colles, to sutures, to abscess drainage – we can do all these things really easily, we just need to get the space and time to do the sedations.
Which brings me to my second point. The “protocol” (or at least just what we do) is to have 2 docs and 2 nurses for any sedation. One nurse looks after the airway, one nurse helps with the procedure, one doc does the procedure and one gives the drugs.
I think that’s a bit of overkill (poor choice of words…) as even the ACEP guidelines on this suggest 1 nurse and 2 docs.
If we didn’t need the extra nurse then it’d be a hell of a lot easier to get a few more sedations done.
Anyone else doing sedation for abscess?
What I do for big abscesses is not really sedation but synergy (so I tell myself); a little fentanyl, a little ativan for calm, and then a local which is a better local because the patient is not screaming in pain.
I realize this may sound like backdoor conscious sedation, but it’s really not. There is no law from on high that says that if you use local, you shouldn’t use any other symptom control.
I&D is painful even with local — pain medicine.
Like any surgical procedure it produces anxiety — benzo.
And life is better for all.
sounds like a good plan to me!
Andy Neill http://EmergencyMedicineIreland.com
Yeah — it’s just humane — for the big ones, or very little kids, or tweaking meth-heads you could never do otherwise. It can be a bit of a hassle, but it’s entirely worth it, especially if the alternative is to occupy an inpatient bed for days and days (?!?). The only ones I admit for the OR are on the axilla, neck, or intermuscular fascial planes.
i think if i keep phrasing it along the lines of “save and admission” I’ll have more joy with getting it done than “humane”. Kind of disturbing but true!
Hi mate. I do a lot if abscesses in ED. We live in a cesspool of staph in the tropics, no day us complete without a few expressions of pus!
Sedation is good – love ketofol personally, it is ideal – you use the propofol window for the cut and squeeze, then the tail for the dressing etc
A few points on ED abscesses:
Doing an US yourself is good value – the rate of disappointing, pusless incisions goes right down. And you can plan the size of your cut/ dissection nicely
Learning US guided nerve blocks is also a great way to avoid having to involve a surgeons input / admission. And it requires not a single nurse
I reckon I will do a few posts. You have inspired me with your pus talk!
Casey @ Broome Docs
I can certainly open an abscess without much in the way of analgesia or sedation but it’s the hoaking around and breaking down loculations that i think i need the sedation for.
I’ve only started using US recently for deciding on whether or not to stick a needle or a knife in and it’s great.
i always loved the idea of local blocks for abscesses but they’re always in the wrong place for regional blocks it seems. Mainly butt-hole abscesses!
Though have you ever tried this?
SUPERIOR CLUNEAL NERVE BLOCK FOR TREATMENT OF BUTTOCK ABSCESSES IN THE EMERGENCY DEPARTMENT
The Journal of Emergency Medicine, Vol. 39, No. 1, pp. 83–85, 2010
Superior cluneal???? Maybe I slept through that dissection in med school
you mean you don’t know detailed anatomy of the individual back muscles? what about rotatores thoracis or multifudus?…
OK I’ll confess I’d never heard of most of those back muscles or the cluneal nerves till i started teaching anatomy so don’t worry i don’t think you missed much!