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Date: September 1st, 2016

Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals Trust (North West England). She did Medical School at Manchester, with a History of Medicine BSc at the same time. Kirsty did her residency in North West England and has a PhD in Health Services Research from Sheffield.

This is an SGEM Xtra summer content episode. But don’t panic we will be back later this month to launch Season # 5 of the SGEM…better, stronger, faster than it was before – cutting that knowledge translation window down from over ten years to less than one year using the power of social media.

In this episode I ask Kirsty five questions about infographics and five questions about her Paper In A Pic (#PaperinaPic) knowledge translation project. Listen to the podcast to hear her responses. You can check out her SGEM infographics by clicking on #PaperinaPic.

Additional Resources and Examples of Infographics:

* Definition of Infographic

* Wikipedia Infographics

* Florence Nightingale; the mother of Infographics?

* Propofology Infographs

* CanadiEM AHA 2015

Video of Kirsty with BatDoc at SMACCDub.

I hope everyone enjoys the last few days of summer and we will be back soon with Season#5 of the SGEM. It will include an exciting new feature for SGEMHOP from AEM.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

“Diltiazem foi mais efetivo no controle da frequência cardíaca nos pacientes da Emergência com fibrilação atrial de alta resposta ventricular sem causar um aumento na incidência de efeitos adversos.”

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Date: July 5th, 2016

Guest Skeptic: Dr. Rodrick Lim. Rod is the Chair for the Pediatric section of the Canadian Association of Emergency Physicians, and the standards lead for the Pediatric section of International Federation for Emergency Medicine. He is an associate professor of Pediatrics at Western University, Schulich School of Medicine. Rod is also the proud father of three children and loves travelling, suffering as a Toronto sports fan and playing hockey badly with colleagues.

This is a SGEM Xtra. Some extra content for the summer until we formally launch Season#5 this fall.

The Pediatric Section of the Canadian Association of Emergency Physicians (CAEP) and the National Emergency Nurses Association (NENA) recently released some tips to keep your family safe and prepared.

You can print a PDF of the Top 10 ED Tips for Families and stick on your fridge, talk to your children, share with your school, co-workers, neighbours and friends, and post to your social media accounts. It is available in ENGLISH and FRENCH.

If you have any questions about this list please contact Dr. Lim at [email protected]

Top 10 Emergency Department Tips for Families

Listen to the podcast to hear Dr. Lim expand on each of these issues.

#10 Vaccinate your children.

There has been an unfortunate & unnecessary return of preventable diseases (e.g. measles, mumps, whooping cough) in Canada over the last few years. These illnesses always find a way into our EDs and our waiting rooms. Protect the very young & the very old in your community (who are the ones most at risk) by ensuring your children all get vaccinated. It’s the right thing to do and, quite simply, it saves lives.

#9 Be a safety role model to your children and promote injury prevention.

A really big part of keeping your child out of the ED in the first place is to teach them to make smart decisions about preventing injuries before they happen. Choosing to always wear a seatbelt, a helmet, and a life jacket is a good start. And PLEASE don’t text & drive – distraction is the #1 killer on the roads! These actions alone can save hundreds of lives across Canada EVERY year.

#8 Promote healthy activities in your family.

Healthy children & adults recover faster from the illnesses and injuries that bring them to the ED. It’s important to balance “screen time” with physical exercise; this applies to both your children and YOU!

#7 Talk to your children about mental wellness.

Be alert to the signs of depression, anxiety or change in mood. Get your primary care provider involved as early as possible and ask them about additional resources available in your community.

#6 Keep all medications and household chemical products in a safe location.

It’s also helpful to keep the phone number for your local Poison Control Centre in an easily accessible location, like the fridge door. Young children can easily mistake pills for candy and sometimes it only takes one pill to kill. If you think your child has taken something, please remember to bring all the suspected bottles or containers to the ED.

#5 If your child has a serious allergy or medical condition, teach them to how to manage their symptoms independently.

Chronic conditions like asthma and diabetes are better controlled over the long term if you and your child are both familiar with how to use medications. Medic alert bracelets are also a good investment as they inform ED staff of your child’s medi...

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Date: July 5th, 2016

Guest Skeptic: Dr. Chris Bond. Chris is an emergency physician and clinical lecturer at the University of Calgary. He is currently the host of CAEP Casts, which highlights educational innovations from emergency medicine residency programs across Canada. Chris also has his own #FOAMed blog called Standing on the Corner Minding My Own Business (SOCMOB).

Reference: Gray A et al. The impact of computerized provider order entry on emergency department flow. CJEM 2016.

Background: Emergency department crowding is a growing issue across Canada. As more tertiary care EDs implement computerized provider order entry (CPOE), it is important to analyze emergency department metrics to see how CPOE may impact throughput.

Previous studies have shown that CPOE has no impact on mortality, and may in fact improve pain treatment and adherence to certain common presenting complaint medication protocols (such as stroke and renal colic) [1-4].

Some studies have shown there may be an impact on throughput in a number of possible areas such as decreased physician productivity, increased LOS for admitted patients, or increased time to order labs and imaging [5-7].

Other studies have shown that CPOE fixes some errors, creates new ones and frustrates physicians [8]. There is no consistent or comprehensive evidence in favor of CPOE [9].

A study looking at productivity in a community hospital emergency department showed the mean percentage of time spent on data entry was more than 40% and less than 30% spent on direct patient care. They calculated in a busy 10hr shift the number of mouse clicks was almost 4,000 [10].

To our knowledge there have been no studies to directly evaluate the impact of CPOE on emergency department wait times, a key variable in throughput and crowding.

Question: What impact will CPOE have on emergency department patient throughput?

Reference: Gray A et al. The impact of computerized provider order entry on emergency department flow. CJEM 2016.

* Population: Emergency department patients 18 years and older presenting to two quaternary hospitals in July and August of 2013 and 2014.

* Excluded: Patients with negative wait times or extreme outliers that exceeded 24 hours (presumed to represent an erroneously wrong day recorded). Also excluded any patients missing vital statistics (eg. Gender, age or CTAS score).

* Intervention: Computerized provider order entry (CPOE)

* Control: Non-computerized order entry

* Outcome:

* Primary Outcome: Emergency department throughput

* Wait Time (WT): Time to first physician assessment after triage (minutes)

* Length of Stay (LOS): Time to disposition after triage (minutes)

* Left Without Being Seen (LWBS): Proportion of patients that LWBS/total patients for a given time period (%)

* Secondary Outcome: Subgroup analysis

* CTAS 1-5 (WT, LOS and LWBS) and admitted patients (WT and LOS)

Canadian Triage and Acuity Scale (CTAS): This was a national program started in (1999) to standardize emergency department triage in Canada.

Author’s Conclusions: ”CPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the inc...

Link zur deutschen Version des Podcasts: SGEMGlobal#156: German

Link zur englischen Orginalversion des Podcasts: #156

Datum: 1. Juli 2016

Disclaimer: Im englischen Original des SGEM und hier in der deutschen Übersetzung wenden wir größte Sorgfalt an, um korrekte Informationen rund um die Notfallmedizin zu geben. Dieser Podcast ist nur an medizinisches Fachpersonal gerichtet. Allerdings sind wir nicht immun vor Fehlern und übernehmen keine Gewähr für den Inhalt des Podcasts und dessen klinischer Anwendung. Jeder ist für sein Handeln selbst verantwortlich und wir empfehlen, diesen Podcast nicht als einzige Grundlage für die Behandlung von Patienten zu verwenden!

Gast im Orginal: Der Gast im englischen Original ist Chip Lange. Chip ist Arzthelfer, der im ländlichen Missouri in der Notaufnahme eines städtischen Krankenhauses arbeitet. Er hat internationale Erfahrung in der Intensiv-und Notfallmedizin. Anmerkung des Autors: Arzthelfer in Amerika sind nicht mit Arzthelfern in Europa zu vergleichen, sie haben in Amerika eine deutliche breitere Ausbildung, aber auch mehr Verantwortung und einen größeren Aufgabenbereich.

Klinischer Fall: Eine 30-jährige Patientin mit einer Reihe von Hautabszessen in der Vergangenheit kommt in Deine Notaufnahme, weil sie denkt, dass sie einen erneuten Abszess an ihrem Arm hat. Sie erzählt Dir, dass so wenig wie möglich getan werden soll, um diesen Abszess zu behandeln, weil sie die Schmerzen der Therapie hasst, vor allem die Schmerzen der Spülung nach der Spaltung.

Hintergrund: Hautabszesse kommen häufig in der Notaufnahme vor und es gibt eine Menge Diskussionen rund um die Behandlung von Abszessen. Die Haupttherapie besteht aus Spaltung und Drainage. Zusätzlich kann man an Wundabstriche, Schmerztherapie und Antibiotika denken. Es gibt eine Menge Dogmen rund um die Wundversorgung.

Der Podcast im englischen Original hat eine Folge dazu aufgenommen (Dogma der Wundversorgung). Es gab eine Folge über das Packing der Wundhöhle nach dem Spalten (#13). Das Fazit damals war, dass es möglicherweise besser ist, normale Abszesse nach dem Spalten nicht zu packen.

Ein anderes Thema ist, ob man routinemässig Antibiotika verschreiben soll oder nicht. Eine Studie aus dem Jahr 2007 (2007) wurde in der Folge 13 des SGEMs besprochen (SGEM#13). Die Studie damals zeigte, dass es kein Beweis dafür gibt, dass man routinemässig Antibiotika bei einfachen Hautabszessen verschreiben sollte, auch nicht bei MRSA.

Im Moment gibt es keine randomisierte kontrollierte Studie, die einen Benefit für die Spülung einfacher Hautabszesse zeigt. Diese Therapie kann schmerzvoll sein, dauert und kostet Geld. Ebenfalls gibt es ein Risiko der Kontamination für den Patienten.

Klinische Fragestellung: Vermindert die Spülung einfacher Hautabszesse nach Spaltung und Drainage die Häufigkeit weiterer Interventionen?

Referenz: Chinnock and Hendey. Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success. Ann Emerg Med 2016.

Patientengruppe: Patienten aus der Notaufnahme, älter als 18 Jahre, mit einem Hautabszess

ausgeschlossen: Schwangere, Gefängnisinsassen, Patienten, die im Krankenhaus aufgenommen oder in den OP gebracht werden und Patienten, bei denen es unmöglich erscheint, ein Follow-Up über 30 Tage zu erreichen

Intervention: Spaltung, Drainage und Spülung

Vergleich: Spaltung, Drainage alleine

Outcome: Notwendigkeit weiterer Interventionen in den nächsten 30 Tagen. Die Interventionen waren weitere Inzisionen, Antibiotika oder Krankenhausaufnahme wegen des Abszesses.

Zusammenfassung des Autors: „Obwohl es Unterschiede in den beiden Gruppen bezüglich der Basisdaten gibt, zeigt sich trotzdem kein Vorteil für eine zusätzliche Spülung bei unkomplizierten Hautabszessen.”

Qualitätscheckliste für randomisierte klinische Studien:

Bestand die Studienpopulation aus Patienten aus der Notaufnahme? Ja.

Waren die Patient ordentlich randomisiert? Ja.

War die Randomisierung verblindet? Ja.

Wurden die Patienten in der Gruppe analysiert[...]

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Date: June 26th, 2016

Guest Skeptic: Dr. Anthony Crocco is a Pediatric Emergency Physician and is the Medical Director & Division Head of the Division of Pediatric Emergency at McMaster’s Children’s Hospital.

He is known on YouTube for his RANThony‘s. These are short rants on pediatric topics. They were inspired by the rants done by the great Canadian comedian Rick Mercer. Previous topics have included Fever Fear, Cough Medication and Pain Control.

Anthony is also the creator of the evidence based medicine (EBM) education website SketchyEBM. These are white board videos that present EBM concepts in a creative and understandable formate. He covers topics like:

* Relative risk (RR), relative risk reduction (RRR), absolute risk reduction (ARR)

* What is bias?

* Confidence intervals and “p” values

* Number needed to treat (NNT)

* Intention to treat (ITT) analysis

This fourth RANThony addresses the issue of x-rays for the diagnosis of pediatric constipation. Click on this LINK to watch the YouTube video and as Anthony says “always draw your own conclusions.”

X-rays for Pediatric Constipation

Introduction: Pediatric constipation is a common presentation to clinics, urgent care centers and emergency departments. The first step in management of pediatric constipation is making the appropriate diagnosis.

Diagnosis:  The NASPGHAN and ESPGHAN concluded in a 2014 guideline that “the diagnosis of functional constipation is based on history and physical examination” and that we use “the Rome III criteria for the definition of functional constipation for all age groups”.

Radiography: A systematic review by Berger (2012) found that there was “insufficient evidence for a diagnostic association between clinical symptoms of constipation and fecal loading on abdominal radiographs”.   The NASPGHAN and ESPGHAN guidelines state that “the routine use of an abdominal radiograph to diagnose functional constipation is not indicated”.

Adverse effects: Aside from the risks of radiation exposure concern had been raised about whether performing xrays in children to diagnose constipation can be misleading. A paper by Freedman (2014) found that “misdiagnoses in children with constipation are more frequent in those in whom an AXR was performed”, that “the presence of stool on AXR does not rule out an alternative diagnosis.” Missed diagnoses included appendicitis, bowel obstruction and intussusception.

Imagine Two Stories:

* A three year-old presents with a history of infrequent stools that are large caliber, painful and plug the toilet. The child has fecal soiling in between bowel movements. Is this child constipated? Yes. Does the child need an abdominal xray to help with this diagnosis? No.

*  A four year-old presents with abdominal pain. Earlier in the day he was at a birthday party where he ate four hot-dogs and two pieces of cake. There is a history of regular bowel movements, which are soft and easy to pass. Is this child constipated? Unlikely. An xray may show fecal loading, which likely represents food digesting in the bowel. Alternative diagnoses should be sought.

Bottom Line: Constipation is a clinical diagnosis based on history and physi...

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Date: June 15th, 2016

Guest Skeptic: Dr. Anthony Crocco is a Pediatric Emergency Physician and is the Medical Director & Division Head of the Division of Pediatric Emergency at McMaster’s Children’s Hospital. He is the creator of SketchyEBM.

Case: A 2-year-old girl presents with a two-day history of vomiting and diarrhea. She is minimally dehydrated and tolerating oral fluid only. You remember reading about the sodium-glucose co-transporter and electrolyte fluids that were initially developed by the World Health Organization for children with diarrheal diseases. You have heard parents ask about just using watered down juice and debate whether this is a viable option for these children.

Background: Gastroenteritis is a common illness in children and these children are at risk of dehydration from inadequate intake, excessive losses or both together. If children are unable to tolerate oral hydration we often have to use intravenous fluids and sometimes require admission to hospital for ongoing fluids.

Goldman et al Pediatrics in 2008 published a helpful table describing the degree of dehydration in children ranging from mild, moderate to severe.

Most cases of gastroenteritis are mild, self-limiting and can be treated effectively with oral rehydration. For more information on visit this site on Oral Rehydration Therapy. The Canadian Pediatric Society also has an algorithm for oral rehydration (see below).

We covered ondansetron on SGEM#12. Bottom line – Ondansetron is an effective anti-emetic preventing further vomiting, intravenous fluids and admissions for children with gastroenteritis.

* NNT of 5 to stop vomiting

* NNT of 5 to prevent one intravenous insertion

* NNT of 14-17 to prevent one admission

We also talked about ondansetron on SGEM#122. For the centers studied, the rates of ondansetron use increased from 0.1% to 42%. However, there was no significant difference in the rates of intravenous insertion or hospitalization during this time frame.

Children with vomiting from gastroenteritis, and mild-moderate dehydration, should have a trial of oral rehydration therapy. Failing this, ondansetron should be administered. Failing that, intravenous fluid should be considered.

Clinical Question: In children with mild gastroenteritis who are minimally dehydrated, is diluted apple juice and preferred fluids as good (or even better) an oral rehydration fluid compared to an electrolyte rehydration solution?

Reference: Freedman et al. Effect of dilute apple juice and preferred fluids vs. electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: A randomized clinical trial. JAMA. May 2016

* Population: Children presenting to the emergency department between six months to five years age. They needed to have three or more episodes of vomiting or diarrhoea in past 24 hours and symptoms could not have been going on for more than 96 hours. The children also needed to weigh at least eight kilograms and have minimal dehydration on the

SGEMGlobal #157: French  – Un bouillon salé pour la bronchiolite!

SGEM#157: Nebulized Hypertonic Saline for Acute Bronchiolitis.

Dr Chantal Guimont.Ph: J Bernier de Focus.

Dr Louis-David Audette, R4, MU5, U Laval

Bienvenue à l’édition française du « Skeptics Guide to Emergency Medicine », le guide des sceptiques en médecine d’urgence

Date: Nous sommes le 7 avril 2016 et je suis votre hôte, Marcel Émond.

Titre:  « Un bouillon « salé » pour traiter la bronchiolite ?». Cet épisode est un épisode original du Guide des sceptiques en médecine d’urgence.

Notre invité est Louis-David Audette, résident senior du programme de médecine d’urgence

spécialisée de l’université Laval.

Il est accompagné de la Dre Chantal Guimont, professeur de clinique à l’Université Laval, Médecin de famille travaillant à l’urgence au centre hospitalier mère-enfant Soleil de la ville de Québec, Canada et détentrice d’un doctorat en épidémiologie.

Cas: Il s’agit d’un enfant de 8 mois amené à l’urgence pour congestion nasale, tachypnée et tirage pour qui vous soupçonnez un diagnostic de bronchiolite légère à modérée. Vous vous questionnez sur le traitement optimal à offrir à ce patient.

Contexte: Durant les mois d’hiver, la bronchiolite représente une proportion importante des consultations à l’urgence. La bronchiolite constitue une infection des voies respiratoires inférieures, ressemblant à une crise d’asthme. Son diagnostic est essentiellement clinique.

Plusieurs hypothèses sous-tendent l’utilisation du salin hypertonique en bronchiolite. Il réhydrate les voies respiratoires, diminue l’œdème épithélial et accentue le transport des sécrétions.

En 2013, Zhang et collègues ont publié une méta-analyse sur la bronchiolite. Cette revue systématique regroupait 1090 patients de 24 mois ou moins atteints de bronchiolite légère à modérée. À la lumière de leurs analyses, ils ont conclue à une tendance à la réduction du taux d’admission, toutefois non significative d’un point de vue statistique.

En novembre 2014, l’American Academy of Pediatrics. Clinical stipulait que « le salin hypertonique nébulisé ne devrait pas être administré aux enfants avec un diagnostic de bronchiolite au département d’urgence »

Aussi en 2014, la Société Canadienne de Pédiatrie déclarait que : « Les données probantes actuelles n’appuient pas fermement la recommandation d’administrer du chlorure de sodium 3 %. »

 

Question : Chez les patients atteints de bronchiole, quel est l’efficacité du salin hypertonique en nébulisation?

 

L’article est : Zhang et al. Nebulized Hypertonic Saline for Acute Bronchiolitis: A Systematic Review. Pediatrics, 2015.

Quelle est la question PICO?

Population: Il s’agit d’une revue systématique regroupant 22 essais cliniques randomisés ou quasi-randominés examinant les enfants de 24 mois ou moins atteint de bronchiolite aigue.

Intervention: un traitement en nébulisation au salin hypertonique de concentration variable (3, 5 ou même 7%) combiné ou non à un traitement de bronchodilatateurs tels que l’épinéphrine, salbutamol, etc.

Comparaison: un traitement comparable au salin isotonique (0,9%) ou un traitement standard.

Résultat: Les auteurs avaient plusieurs résultats primaires : la durée d’hospitalisation chez les patients admis et le taux d’admission chez les patients ambulatoires. Nous allons ici nous concentrer sur le taux d’hospitalisation puisqu’il s’agit de l’issue qui nous intéresse en salle d’urgence.

Ils avaient plusieurs issues secondaires : la diminution du score de sévérité clinique et les événements indésirables.

Les conclusions de l’auteur sont : « En conclusion, cette nouvelle revue systématique démontre que le salin hypertonique nébulisé est associé à une réduction moyenne de 0,45 jours, c-à-d 11 heures, dans la durée de séjour des enfants admis pour bronchiolite aigue, ainsi qu’à une réduction de 20% du risque d’hospitalisation chez les patients ambulatoires. »

Les critères d’analyses pour les revues systéma[...]

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Date: June 6th, 2016

Guest Skeptic: Dr. Chantal Guimont. Chantal is a Family Doctor who works in a in a mixed pediatric and adults tertiary care center in Quebec City. She has a PhD in epidemiology and is on faculty at Laval University.

Case: You are working in the emergency department when an eight months old presents with nasal congestion, tachypnea, and retractions. You suspect he suffers from a acute bronchiolitis. You wonder about the most accurate and up to date treatment options.

Background: During winter months in Quebec, and I suspect it is the same in many other places, bronchiolitis is one of the most frequent emergency department complaints.

Bronchiolitis is the most common disease of the lower respiratory tract infection seen in children less than one year of age. They tend to present similar to an asthma exacerbation (coughing and wheezing). It is usually a mild illness needing only supportive care. However, it can be a more serious illness requiring hospitalization and rarely causes death.

A good history and physical exam are sufficient to confirm the diagnosis. Treatment usually involves supportive care and supplemental oxygen if oxygen saturations are below 90%.

Many treatments similar to those given to asthmatic children have been tried (example: beta-agonists, ipratropium, oral and inhaled steroids). These asthma treatments and antibiotics have been shown not to be effective for the treatment of bronchiolitis.

3% hypertonic saline (HS) is a newer treatment option. In theory, it rehydrates the respiratory tract, thins the epithelial edema and enhances secretion clearance.

In 2013, Zhang and colleagues published a meta-analysis on acute bronchiolitis. In this systematic review, there were 1,090 children aged up to 24 months with mild to moderate viral bronchiolitis. According to their analyses, they concluded that even if a tendency to reduce hospital admission was observed, there was no statistical evidence of an effect of nebulized hypertonic saline on hospital admission.

In November 2014, the American Academy of Pediatrics Clinical Practice Guidelines recommended that “Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department” (AAP 2014).

Also in 2014, the Canadian Paediatric Society declared that “Evidence does not currently support its routine use in the outpatient setting” (CPS 2014) .

In June 2015 the National Institute for Health and Care Excellence (NICE) put out their guidelines for the diagnosis and management of bronchiolitis. They too do not recommend hypertonic saline to treat children with bronchiolitis.

Clinical Question: Is nebulized hypertonic saline safe and effective for acute bronchiolitis?

Reference: Zhang et al. Nebulized Hypertonic Saline for Acute Bronchiolitis: A Systematic Review. Pediatrics 2015.

* Population: RCTs or quasi-RCTs of infants up to 24 months of age with diagnosis of acute bronchiolitis

* Exclusions: Studies that included patients who had had recurrent wheezing or were intubated and ventilated, and studies that assessed pulmonary function alone.

* Intervention: Nebulized hypertonic saline (≥ 3%) alone or mixed with bronchodilator

* Comparison: Nebulized normal saline alone or mixed with same bronchodilator or standard care.

* Outcome:

* Primary outcomes: Length of stay for hospitalized patients and admission rates for outpatients.

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Date: May 25th, 2016

Guest Skeptic: Chip Lange is an emergency medicine Physician Assistant (PA) working primarily in rural Missouri community hospitals. He has international experience in critical care and emergency medicine. Currently, he is working on developing a new blog and podcast specifically for PAs in emergency medicine but wants all those who take care of critically ill or injured patients to be able to learn.

Case: A 30-year-old female with a history of cutaneous abscesses comes to your emergency department stating she thinks she has another one developing on her arm. She tells you she wants to do as little as possible to treat the abscess using an incision and drainage because she hates the pain from the procedure, especially the irrigation.

Background: Cutaneous abscesses are a very common complaint in the emergency department and there is much debate about the management of abscesses. The mainstay management of an abscess is incision and drainage. Other management may include wound culture and sensitivity, pain control, packing and antibiotics.

There is lots of dogma around wound care and we have covered some of these issues before on the SGEM (Dogma of Wound Care). With regards to abscesses we have discuss packing or not packing. Our bottom line in 2012 was that routine packing of simple cutaneous abscesses might not be necessary (Better Out than In).

Another issue that has been debated is whether or not to routinely prescribe antibiotics. A study by Hankin and Everett. Are Antibiotics Necessary After Incision and Drainage of a Cutaneous Abscess? was published in Ann Emerg Med 2007. We reviewed this paper on SGEM#13. Our conclusion at that time was that the evidence did not support using antibiotics routinely in simple cutaneous abscesses even in the era of MRSA.

A new study looking at Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess by Talan et al was published in NEJM March 2016. We will be reviewing this study soon on the SGEM.

Apparently there is no randomized controlled trial demonstrating the benefit of irrigation in the treatment of simple cutaneous abscesses. Treating these conditions can be painful, takes time and has a financial cost.There is also the risk of contamination to the patient and emergency medicine provider, like the PA doing the irrigation. 

Clinical Question: Does irrigation of a cutaneous abscess after incision and drainage reduce the need for further intervention?

Reference: Chinnock and Hendey. Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success. Ann Emerg Med 2016.

* Population: Emergency department patients >18 years old with a cutaneous abscess

* Excluded: Pregnant, police custody, prison resident, admitted to hospital, taken to the OR, inability to follow-up in 48hrs or to provide contact information for 30-day follow-up.

* Intervention: Incision and drainage plus irrigation

* Comparison: Incision and drainage alone

* Outcome: Need for further intervention in the next 30 days after the initial incision and drainage (Interventions include: repeat incision and drainage, antibiotic change, or abscess related hospital admission within the next 30 days).

Author’s Conclusions: “Although there were baseline differences between groups, irrigation of the abscess cavity during incision and drainage did not decrease the need for further intervent...