What are the steps to performing an incision and drainage of an abscess?
- Anesthetize the skin using more lidocaine than usual (increased circulation at the inflamed site carries the drug away rapidly)
- Open the lesion with a #11 blade
> Wear eye protection
> Can use a cruciate incision or a linear incision - Let the contents drain from the opening
- Gently express the contents of the abscess
> Caution: can be very painful and projectile - If needed, break up pockets within the cavity using a hemostat and blunt dissection
- Pack the cavity with an iodine impregnated gauze
> Caution not to overpack - Dress the wound after applying calendula or minor surgery tincture
- Have the patient change the dressing daily, being careful not to remove the drain
- Have the patient return in three days to have drain and any new pus removed
- Repack the wound with less packing than originally used
> Allows the wound to heal from below - Repeat daily dressing changes at home until the induration and redness clear and the wound is healing well
- If drain left in, patient returns every three days to have it removed and repacked until it’s completely removed
- Can also have the patient advance the drain and trim the end and re-bandage daily
What are the possible pitfalls of attempting to drain an abscess before it has formed (ripened)?
- Bleeding without obtaining drainage
- Potential of spreading the infection
Why use a cruciate incision to drain an abscess?
- It helps prevent premature wound closure during drainage and healing
Review Lift-and-Snip
- Use 18-22 gauge needle to draw up anesthesia
- Use a 27-30 gauge needle to inject the anesthesia
- Create a cutaneous bleb with anesthesia
- Grasp lesion and elevate it a moderate amount
- Snip off the lesion with sterile iris scissors
- Apply direct pressure or cautery to oozing wound or bleeders
- Dress with minor surgery tincture on bandaid
Review Shave Biopsy
- Use 18-22 gauge needle to draw up anesthesia
- Use a 27-30 gauge needle to inject the anesthesia
- Create a cutaneous bleb with anesthesia
- If possible, grasp lesion with forceps and elevate
- Shave off lesion with #15 or #10 scalpel
- If cannot elevate it, use either a scalpel or a Dermablade
- Apply direct pressure or other means to control oozing wound or bleeders
- Dress with minor surgery tincture on a bandaid
Review Scoop Biopsy
- See video
Review Punch Biopsy
- Prep with alcohol, anesthesia, and Betadine
- Stabilize the skin with thumb and index finger
- Firmly press the punch tip perpendicular to the skin surface
- Rotate back-and-forth until you feel the punch drop through the skin
- Grasp specimen with tissue forceps and snip through the sub-q layer with iris scissors
- Apply direct pressure or cautery to small oozing wound or bleeders
- If needed, close wound with sutures
- Dress with minor surgery tincture on a bandaid
What should be the configuration ratio and angles for an ellipse?
- Ellipses should be 3:1 configuration ratio with 30 degree angles at the ends
Why is the goal to cut skin edges perpendicular to the surface when doing elliptical excisions?
- Allow for better eversion on closure
What are the options for treatment when a wound dehisces?
Partial (1 or more sutures open)
- Watch for infection
- Debride/clean/bandage as needed
- Monitor suture tension
- Let heal by second intention
Larger
- Open, debride/clean, irrigate
- Re-suture if no sign of infection and less than 24 hours has passed
- If infection is present, consider second intention and/or antibiotics
What are the two options as methods of anesthesia for removing part/all of a finger/toenail?
- Digital block
- Ring block
What are two reasons for/advantages of using a Running Lock stitch?
- Makes a watertight seal
- Good for gathering loose skin, like on the scrotum
