Procedure Preparation of the pediatric patient for abscess drainage is critical and includes pharmacologic anxiolysis or sedation and pain management in most instances (see Chapter 129 Procedural Sedation ) Parenteral use of ketamine for procedural sedation is often required in children with complex or large abscesses The application of EMLA or other topical anesthetic cream may be of value in anesthetizing the superficial epidermis but should not be considered an adequate pain management technique by itself due to inadequate anesthesia of deeper soft tissue structures Distraction techniques and the use of child life may also help to reduce anxiety and pain Immediately prior to beginning the procedure, position the child to maximize access to the abscess For example, in case of a cervical neck mass ( Fig 130.33A ), place the child supine with head turned 90 degrees away from the midline to expose the neck Have an assistant stabilize the patient at the site of the procedure, and restrain as necessary Local anesthetic (lidocaine 1%) injection in a field block 360 degrees surrounding the abscess will reduce pain Ultrasound can be utilized to determine the size/depth of the abscess cavity and proximity to vascular structures This should be followed by lidocaine injection linearly along the abscess where the incision is to be made ( Fig 130.33B ) In very small, superficial soft tissue abscesses, occasionally the topical anesthetic may be sufficient if appropriate pain relief has been achieved with adjuvant medication FIGURE 130.33 Incision and drainage of an abscess Incision and Drainage Preparation of the site includes cleansing of the skin with antiseptic solution With a no 11 scalpel blade, incise the skin over the abscess parallel to the natural creases of the skin to the depth of the superficial fascia Then, bluntly open the abscess with a hemostat for at least cm, as shown in Figure 130.33C Insert the hemostat into the abscess cavity to break up any septae, remaining cognizant of potential underlying structures Obtain cultures of the purulent material if clinically indicated and express as much purulence from the cavity as possible The abscess cavity may be irrigated with normal saline to facilitate removal of debris Pack the wound lightly with a packing strip leaving to cm of the strip outside of the cavity This will function to physically keep the wound open to promote further drainage Dress the wound with an absorbent dressing, which will draw additional drainage away from the skin surface Remove the packing in to days The utility of antibiotics in addition to incision and drainage is unclear; some recommend antibiotic use when there is significant surrounding cellulitis or systemic symptoms such as fever Vessel Loop Method of Incision and Drainage Incision and loop drainage is a minimally invasive technique for abscess management in children using a silicone vessel loop, a small Penrose drain, or a sterile rubber band It has gained popularity over the past decade due to various advantages over the traditional I&D method: (1) no packing changes, (2) smaller incisions leading to better cosmetic results, (3) ongoing drainage while the loop is in place Using a no 11 scalpel, make a small incision (5 to 10 mm) at one edge of the fluid collection, preferably where it extends closest to the skin surface or where it is already draining Use a hemostat to probe the cavity and break up loculations without damaging adjacent or underlying structures Obtain cultures of the purulent material if clinically indicated and express as much purulence from the cavity as possible Use the hemostat to probe to the opposite edge of the cavity and tent the skin where the second incision will be made Use the no 11 blade to make another incision over the hemostat tip The two incisions should not be further than cm apart Larger abscesses may require placement of multiple loops Attach a plastic intravenous catheter to a syringe and irrigate the cavity to remove debris (Alternatively, this irrigation technique can be done once the loop drain is securely in place.) Insert the hemostat so that it enters one incision, tunnels through the cavity, and exits via the other incision Use this hemostat to grab the vessel loop and pull it through the cavity so that the loop replaces the hemostat in each incision site ( Fig 130.34A ) Tie the two ends of the vessel loop without tension so that a finger can be easily inserted between the skin and loop ( Fig 130.34B ) To avoid tension, a syringe can be placed between the skin and loop material while tying the ends and removed after the drain is secured Trim the ends of the drain Cover the wound with an adsorbent dressing as it will continue to drain This dressing should be changed at least twice a day for the first days The patient should shower or bathe twice a day with the dressing removed but with the loop still in place The loop can be gently pulled back and forth once or twice a day to keep the wound open and promote continued drainage The drain is removed by cutting the loop and pulling it out when the discharge stops and healing is noted (usually to 10 days) FIGURE 130.34 A, B : Vessel loop method of incision and drainage (A, B: Reprinted with permission from Mayeaux EJ Essential Guide to Primary Care Procedures 2nd ed Philadelphia, PA: Lippincott Williams and Wilkin; 2015.) CLOSED REDUCTION OF DISLOCATIONS Finger/Toe Joint Dislocation Indications