Trick of the Trade: Incision and loop drainage of abscesses

Why are we still teaching the traditional incision and drainage approach to simple abscess drainage? They require frequent, painful packing changes to ensure persistent drainage of retained pus.

Trick of the Trade

Incision and loop drainage (I&LD) technique

As per usual, Dr. Rob Orman (ercast) beat me to this. He already reviewed the technique on his blog in 2010. This stems from a landmark article in the Journal of Pediatric Surgery, which involves creating a persistently draining fistula at two points by using a small vascular loop, tied into a non-tensile loop.

It makes sense to extrapolate and use this technique for both pediatric and adult patients with uncomplicated abscess, especially if the patients may not follow-up for packing changes as scheduled. The added benefit is that showering is encouraged to help encourage drainage without the risk of dislodging the secured loop.

Questions

Does anyone have experience with this that they would like to share? Particularly, what if you don’t have the skinny vascular loops in your Emergency Department?

What are the follow-up instructions?

Per the Tsoraides article¹:

Take a bath/shower TWICE daily for the first 3 days.
Remove the loop in 7-10 days (when the drainage stops and the overlying cellulitis resolves)

Reference

Tsoraides S, Pearl R, Stanfill A, Wallace L, Vegunta R. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010;45(3):606-609. [PubMed]

By Michelle Lin, MD|2021-01-02T13:55:50-08:00Aug 14, 2012|Tricks of the Trade|

Paucis Verbis: Overanticoagulation and supratherapeutic INR

I find it amazing that I know more non-emergency physicians virtually in the social media world rather than in person. Primarily through Twitter, I follow and am followed by medical educators from various specialties. If you haven’t joined Twitter yet, I think it might be time. There is a whole world of collaboration and conversation going on in this virtual community, which crosses specialties and geography.

Last week, Dr. Javier Benítez (@jvrbntz) was tweeting a Question of the Day, referencing a 2010 Paucis Verbis card on overanticoagulation, which was based on the 2008 American College of Chest Physicians (ACCP) guidelines. About 8 minutes after I retweeted his question, Dr. Roy Arnold (@cholerajoe), a pulmonary/critical care physician kindly informed me that the 2012 ACCP guidelines have been out since February.

So this PV card is replacing the 2010 card with revised recommendations. For more in-depth discussion, definitely take a look at Dr. Scott Weingart’s great podcast over at EMCrit. He helps to clarify holes which the 2012 ACCP guidelines don’t really address such as:

What if the patient is minorly bleeding with a high INR?

Oral vitamin K and 15 mL/kg FFP

What if you only have the 3-factor PCC (factors II, IX, X) and not the recommended 4-factor PCC (factors II, IX, X plus factor VII)?

If PCC is indicated, add recombinant factor VIIa or FFP to the 3-factor PCC to cover for factor VII.

PV Card: Overanticoagulation and Supratherapeutic INR

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Holbrook A, Schulman S, Witt D, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e152S-84S. [PubMed]

By Michelle Lin, MD|2021-10-10T08:47:06-07:00Aug 10, 2012|ALiEM Cards, Heme-Oncology, Tox & Medications|

Mythbuster: The 10% cephalosporin-penicillin cross-reactivity risk

To give or not to give a cephalosporin in penicillin-allergic patients?

I remember back to my days in pharmacy school when I learned that there was approximately a 10% risk of cross-reactivity, if a cephalosporin was given to a penicillin-allergic patient. They probably said something about the risk being less with 3rd and 4th generations cephalosporins, but lets be honest… who remembers anything but that magic 10%? When I started working more with physicians, I found that they also learned the same 10% rule in medical school. Well, I guess that means it’s fact, right? Not so fast!

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2018-05-28T22:12:57-07:00Aug 9, 2012|Tox & Medications|

Trick of the Trade: Ring removal using oxygen mask strap

Creative emergency physicians exist worldwide. Check out this nifty trick on ring removal by Dr. Simon Carley (Centre For Evidence Based Emergency Care at Manchester Metropolitan University) of St.Emlyns fame.

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By Michelle Lin, MD|2019-06-19T12:49:24-07:00Aug 7, 2012|Tricks of the Trade|

Sort me! Paucis Verbis cards now catalogued

After much recent feedback on the poll about the Paucis Verbis cards (thanks to all who responded!), I see trends:

Several have commented that it is getting increasingly difficult to find a card that they are searching for. There are over 100 cards now! So, I managed to figure out how to embed a Google Doc spreadsheet into the blog, which now allows you to sort and search for particular cards (minor HTML coding necessary). This list will permanently live on the Paucis Verbis page.

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By Michelle Lin, MD|2019-01-28T22:21:47-08:00Aug 4, 2012|ALiEM Cards, Social Media & Tech|

Poll: Is anyone using the Paucis Verbis cards?

Feedback is essential for continued growth and improvement in any longitudinal project that you work on.

Thus annually, I conduct a poll to see if I can improve anything on the blog. This year, I wanted to focus on the Paucis Verbis pocket cards. There are over 100 cards now, which are each based on recent peer-reviewed publications. I try to make them as practical as possible with the goal of improving evidence-based practice at the bedside.

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By Michelle Lin, MD|2017-03-05T14:14:30-08:00Aug 2, 2012|ALiEM Cards|

Trick of the Trade: Massaging a mandibular dislocation back in

Continuing the theme of mandibular dislocation tricks (protecting your thumbs, post-reduction stabilization), Dr. Daniel Gromis from Advocate Christ Medical Center describes a novel reduction technique, based on the Cunningham shoulder reduction technique using muscle relaxation.

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By Michelle Lin, MD|2019-01-28T22:17:16-08:00Jul 31, 2012|ENT, Tricks of the Trade|