What’s that red thing doing in an abscess??

At the course and in the book, we suggest that physicians should be wary of important neighboring structures. Even with EDE/POCUS guidance for abscesses, this is still a pitfall. I recently saw a young male who is an IV drug abuser. Yes, we do have those in Sudbury! He had injected himself and developed an abscess just proximal to the left antecubital fossa. We learn in our training to use caution when draining abscesses in the area of neurovascular bundles. Of course, the antecubital fossa is one of those areas. Before draining an abscess in this area, pick up your probe and scan the abscess! This patient’s scan is a good example of why.

So, the abscess is filling the screen, with the brachial artery tracking through the middle of the abscess. Without color Doppler, the area in the middle might just seem like debris within the abscess. But when you turn on Doppler, the presence of the artery becomes obvious. Who should drain this abscess? Depending on where you work, it might be the emergency physician or the surgeon. Prudence would dictate that it be the physician with the most experience who drains such an abscess. Regardless of who drains an abscess like this, they can use EDE/POCUS to guide the drainage. Note the location/depth of the artery. Incise the skin away from the artery, and just deeply enough (and no more) to get into the abscess. Normally, one would routinely use a hemostat or another instrument to break up any possible loculations. But with an artery present in the area, that maneuver is to be avoided. In any case, one can also use EDE/POCUS to see if there are multiple loculations or not. In this case, there was only one cavity. One superficial incision into the abscess cavity was all that was needed to make the pus flow.