A Pus Opus
Broome is possibly one of the pus capitals of the world. We have pus in all shades, colours and odours. High rates of Staph. and strept disease combined with a humid, hot environment where nobody ever wears shoes (no matter how bad their diabetes) means that we see a lot of skin infections.
Most of us think we are good at picking the cellulitis from and abscess – or on a more practical level – whom we attack with a scalpel and who we just poison with antibiotics! But are we really good at it – clinically picking cellulitis from a drainable collection?
The boys from Emergency Ultrasound Podcast recently did a podcast on quinsy – and buried in there was a reference to a nice observational study that looked at ED docs, their guess as to wether the cellulitis was really an abscess, then an US in the ED, and numbers on how often they changed their management asa result. The study was by Tayal et al, in Acad. Emergency Med 2008. Basically it showed that they were wrong a lot: about half of the “cellulitis” patients had a drainable collection on US – and management was surgical. And nearly 3/4 of the ones they thought were abscesses were managed by either antibiotics or ‘further investigation’ – that is: they ended up cutting a lot less people unecessarily.
For me this confirmed my suspicions – my in-my-mind-casey-series, I have found that I cut a lot less since I started running the probe over the area and looking beneath the skin. It takes about a minute to do, and saves a lot of time and pain in the ED.
So – I scan more and cut less – everybody wins!
Now, if you do find an abscess and decide to drain it – how should you do it and should you pack it with gauze etc?
I found these gems of knowledge as I was researching this topic and thought I should share. Packing the abscess cavity has always been taught as a way to keep the cavity open to allow drainage and prevent recurrence / recollection of the pus. Sounds goo in theory – but it might just be one of those medical memes that don’t really stand up to the light of closer study. Ashley Shreeves from the NNT did a review on this and found a few studies that compared packing vs. no-packing techniques and ‘open’ vs ‘Closed’ surgical approaches. Basically the techniques resulted in no difference in outcomes and the packing was significantly more painful than not packing – so from a patient’s POV it would seem an unnecessary thing to do!
So, now you are probably asking: what is a closed technique? Well it seems that a closed approach involves doing an incision, drainage and then suturing the wound closed – this was surgical heresy where I trained. We were told to never closed a pus cavity -it must be left open to let out the bad juju. Last year this review in the American Journ Of Emerg Med by Singer et al showed that this was not true. Healing was significantly faster in the closed group than the open group, and there was no significant difference in recurrence rates. So maybe we should sew these up? Love to hear your current practice and how this data effects it…
Finally I would like to recommend this offering from Rob Orman of ERCast fame. Rob delivers a punchy video describing his “loop abscess drainage” technique. I guess this is the same deal as draining and then closing if done well. I think it is an approach I might try for a while and see how the patients like it – it might be a winner – and for me the most important thing is a happy patient with a small scar and less pain.
Let me know if you have a technique that achieves all this.