Simple Abscess Clinical Practice Guideline

 

Burgerpic

By Rebecca Burger (beckyburger@emory.edu)

In the emergency department we implemented a simple abscess Clinical Practice Guideline (CPG) almost one year ago. Here is some key information about the CPG and about loops.

Which patients require I&D in the ED?

Abscess ≥ 1cm in diameter. Smaller abscesses may be lanced with a scapel after LMX is applied.

What is a “loop?”

A loop or vessel loop is a silicone string that has been used in the surgical world and in recent years has been adapted to ED use for treating abscesses.

How is the loop placed?

Using a scapel, a stab incision (~1cm long) is made in the abscess. The wound is probed with a hemostat to break up loculations and drain the pus. A second stab incision is made on the other side of the abscess pocket. The loop is pulled into the pocket through one incision and pulled out through the second incision. Then the loop is tied securely external to the patient to create a “loop.”

What does the CPG say regarding antibiotics?

Consider antibiotics for abscesses ≥ 5cm or in patients < 6 months, febrile with no other source, ill-appearing, inadequate I&D, significant co-morbidities or difficulty following-up. Clindamycin (or Bactrim (< 8yo) or doxycycline (≥ 8yo) for clindamycin allergic patients) is recommended for 7-10 days.

What care instructions are patients given?

  • Keep the area covered with a clean dressing to absorb the drainage and protect the loop from getting pulled on.
  • The child should shower, bathe (with the bandage off), or apply warm compresses twice a day to encourage all the pus to come out and apply a clean dressing after bathing.
  • The loop can be removed once the drainage has stopped and the surrounding infection is much better (less redness, swelling, pain) in 5-7 days at PCP’s office

How do I know if the loop is ready to be removed?

There should no longer be any fluctuance in the surrounding area. There should be no or minimal drainage at the two stab incision sites.

How do I remove the loop?

Simply cut the loop with scissors and pull it out of the patient. This should be very quick and relatively painless. There is no need for sedation for loop removal.

What care instructions should I tell patients after loop removal?

– Continue to soak the area at least once a day until the skin closes to promote further drainage

– The child can leave the wound open to air or cover based on location and personal preference

– There should be minimal scarring long term

loop7monslater

Vessel loop healing on the right

loop procedure 3

Image of vessel loop placed in an abscess

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