The protocol for Cutaneous Abscess:Cutaneous abscess
Let’s break it down!
Abscesses are just collections of pus that can develop anywhere along the body: the brain, abdomen, liver, and so forth. For this protocol, we’re focusing specifically on the cutaneous or “skin” abscess.
Abscesses form anytime you have bacteria that gets into a break in the skin. Usually, this bacteria is Staph aureus. which is naturally occuring on human skin and is responsible for up to 60-75% of uncomplicated abscess cases. Once the bacteria enter the skin, the body sends an immune response to fight over the invading pathogen. The result is a battlefield of dead bacteria, tissue, and immune cells that make up that gooey pus.
Abscesses are extremely common, accounting for over 3 million annual visits to the emergency department. Soldiers are at particularly high risk for skin abscesses in the deployed setting due to poor hygiene and close-quarters living.
For a deeper dive into the pathophysiology, watch the osmosis video below:
Cutaneous abscesses come in all shapes and sizes. Technically speaking, your average pimple is considered a cutaneous abscess 🤔
But the abscesses we’re looking for are a bit deeper (under the dermis or subcutaneous tissue) and at least 1 – 3cm in length, if not larger.
You’ll notice the signs and symptoms listed in this protocol are pretty much the same as what you would find in cellulitis (bacteria makes things big, hot, and painful!🔥) The key one to note though is fluctuance, which by definition is described as a tense area of skin with a wave-like or boggy feeling upon palpation. This is the pus that accumulates beneath the epidermis. You’re basically just feeling for anything moving underneath the skin. You may or may not feel fluctuance during the early stages of an abscess, but eventually, you will. Ultimately, touching and feeling are going to be your primary methods of making this diagnosis.
Other ways to make a more definitive diagnosis include using ultrasound or even CT scans (for deep abscesses). However, you won’t likely have this available in the field.
The video below shows a compilation of classic cases of cutaneous abscesses:
In modern emergency medical practice in the civilian sector, antibiotics aren’t typically prescribed for uncomplicated abscesses that can be drained. In fact, antibiotics don’t typically penetrate into abscesses well anyway. However, given the nasty environment soldiers are in and the risk for cellulitis, antibiotics can be given prophylactically to prevent further infection.
As stated earlier, the most common causative bacterial agent for abscesses is Staph. aureus, which is a gram-positive bacteria. We have LOTS of antibiotics that can cover for it so pick your poison:
Of the four, the two most recommended are Clindamycin and TMP-SMZ. These two have been studied the most for abscesses and they both cover for MRSA (Methicillin-resistant Staphylococcus aureus) which can be particularly difficult to treat.
Instructions are all there, but if you’re like me and you need to visualize this procedure being done, watch the video below (demonstration on silicone model) or click the link below for a live demonstration:
I won’t beat a dead horse, but here are just a few notes on I&D:
- You shouldn’t attempt an I&D in the tactical setting unless the abscess is CLEARLY well-demarcated, superficial, or can be discerned by ultrasound 🧐
- In one study, I&D of skin abscesses was rated as the second most painful procedure by patients next to only NG tube insertion🏅. If you don’t have the appropriate local anesthesia, you should not attempt it.
- You may have heard of “Needle Aspirations” as a method of draining an abscess, which involves sticking a needle inside the abscess and draining it that way 💉. It’s shown to be useful for deep abscesses, but it has a very high failure rate, so it is not recommended
- Irrigation of the wound with normal saline sounds tempting after you’re done, but you should really only do for the really dirty wounds. Routine use of water irrigation has not been shown to be effective
No need to evacuate, you got this. However, you should definitely consider a Priority evacuation if the abscess is in a critical area (head, neck, hand, joint, perineal, eyelid, face, neck) or if it cellulitis ensues around it. Always practice good judgment and lean on the side of caution.
Good luck out there!
- Stapczynski JS, Tintinalli JE. Tintinallis Emergency Medicine: a Comprehensive Study Guide, 8th Edition. New York: McGraw-Hill Education; 2016.
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.
- EMCases: Skin and Soft Tissue Infections
- RebelEM: Is it necessary to irrigate abscesses after I&D?
- UpToDate: Cellulitis and Skin Infections in Adults: Treatment
- EMRAP: Skin and Soft Tissue Infections