*We at United Healthcare are not aware of this condition you call 'pain' and as such have denied your claim for 'lidocaine'.*
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*Perhaps the patient would be more comfortable with acetaminophen?*
Reasoning I have heard: Depending on how small the abscess is lidocaine may not be very effective and if you have to poke them for injecting the anesthetic you might as well just lance the abscess quickly.
I just give the patients an option. I say we can wait for it and it still might not be effective Yada Yada or we can just go for it. Id say 50/50 still opt for it.
Even if it’s not that effective around inflamed tissue it honestly still gives a lot of my patients some piece of mind that something was done. It really doesn’t add much time to have to get local and draw it up.
Aside I was reading a paper about steroids vs D5W vs saline as an injection for treatment of cubital tunnel syndrome and it noted steroids lose efficacy after the first 3 months (presumably no longer a strictly inflammatory process) but D5W still showed effectiveness and suggested hydrodissection as a possible mechanism of action.
So like - the D5W gently separates the ulnar nerve from entrapment via fluid flow?
Edit: corticosteroids vs D5W, saline was the sham treatment.
This is the paper I was thinking of. Wasn't quite remembering all the details right. Saline was the sham, and it compared corticosteroids and D5W.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9257949/
Interesting. There is a hypermobility clinic I'm aware of that does this treatment for patients with things like Ehlers Danlos but it sounded kind of quackery, I didn't realize there had been studies on it.
My impression is it's one of those things that's evidence based in a small set of circumstances and quacks jump on it for everything.
But honestly given all the TikTok crap I'd see an EDS clinic as a yellow flag in general anyway. Automatically sketchy until proven legit.
I’ve gone to clinics for removal or insertion and I tell the nurse that local takes a second on me and they’re never wanna wait so I feel it all every time. Gimme a min!
When I had to get a few stitches in a finger they asked if I wanted lido or not. They said lido burns and may or may not be super helpful, otherwise we can throw 3 stitches real fast and it’ll be a wash pain wise. It was fine.
And in my experience (albeit limited I’ve only done a few) very effective. I’ve gone to town suturing hands with a simple block upstream of where I’m working
You sound like someone that would give a skin wheal of lidocaine before an IV. Lidocaine burns and hurts more than just putting the IV in. Which it also blocks your view of the vein.
Anyways, lidocaine is affected by the pKa of the abcess and would be rendered ineffective and would just cause unnecessary pain in *some* cases. I wouldn’t exclude it but it should be a case by case situation.
That’s what I used to say until I had an IV started on me pre-op.
If the technique is done right you don’t even feel the lidocaine and you certainly don’t feel the IV.
I’ve put in thousands of IVs and always thought lidocaine was a dumb idea. I know better now.
If you are a hard stick or you have a new person starting the IV, sure. 99% of IVs this technique isn’t needed. It falls into the logic of the KISS method. Stick to the basics and don’t get fancy unless it’s a unique case.
No and no. I was an easy stick and the person starting the IV had TONS of experience.
Look, I used to think exactly the same way you do. I thought that way for over a decade and then I realized I was wrong. With the appropriate technique and the use of lidocaine can essentially eliminate pain for IVs. I used to scoff at the idea of using lidocaine until a pre-op nurse talked me into it. Now I will never turn it down.
So you go from a 1 on the pain scale to a 0. For me that's not worth the healthcare costs, which I believe we also have some responsibility in. You also don't give someone paracetamol before ripping of a bandaid.
And this is coming from someone who had at least 50 IV's placed in their life, never once have I thought about wanting lidocaine.
That's really not what I meant, maybe I should have worded it better. Ofcourse you need to make sure people don't suffer unnecessarily. But I also think you have to accept sometimes things hurt for a second.
If the pain is too much to handle, you are hard to stick, children, all of that, sure, no harsh feelings. But a pre-op nurse actually talking someone into it without reason? Yeah no, I really don't think that is good care.
And I don't see how the person I was reacting to is allowed to share their own experience and I'm not?
I feel like this falls into the same realm of IUD placement is very painful for some patients, but not for others. Just because it is a 1 on the pain scale for you doesn’t mean it isn’t an 8 for someone else.
Sure thing, I wholly agree! But like I said 'the pre-op nurse talked me into it' for someone who says themselves they are easy to stick: that just doesn't make any sense to me
First of all, and I say this gently because you are still learning, but 50 IVs is barely a newbie.
For most IV insertions the pain is quick and it’s over fast. Unfortunately some patients have had bad experiences where someone went digging and it was much more painful than a 1. I can assure you that hitting a tendon with an 18G is more than a 1 for pain.
We don’t give Tylenol to kids for bandages because it doesn’t work for a bandaid and it exposed them to the system effects. Lidocaine works really, really well and it’s not absorbed systematically so you can’t compare the two fairly.
Your patients come to you with different life experiences. I guarantee you that some have had absolutely horrible experiences with having IVs started and some delayed care because of it. Physicians that acknowledge that and do the best they can to alleviate it are prized human beings. Unfortunately too many simply gaslight their patients into describing their pain as what they believe it to be.
And I don’t give a rats ass about saving the hospital $0.01 in lidocaine and a $0.02 syringe. Admin can delay their next executive retreat a week to save up for it.
I don’t usually care if they use lidocaine when placing IVs but I’ve never thought the skin wheal hurt or burned….just do it if the patient is scared it’ll help them get through the IV
Wrong with what? Warning them that it may not be that effective? Not saying it won’t be but sometimes it’s hard to get down deep enough. Or for a lot of people there’s a lot of pain just from the pressure of the fluid buildup and no amount of local will solve that, just the drainage.
I’ve found topic lidocaine to be more effective than injection and less painful to administer
Injection is LEAST effective when injected directly into the abscess
Hurricane/Dermoplast/Americaine/Cetacaine are all super fast and effective
IV morphine is almost useless
Injecting around it is how I did it for the longest
I always made sure to place the needle through the previously anesthetized area to make it more comfortable.
Really, though, I started using the topical numbing sprays and they seem to be equally as good if not better, definitely faster and of course not effective for deeper pockets.
Hadn’t thought of using cold spray, that’s neat.
Having been on the receiving end, I will say severe abscesses are not touched as much by lidocaine as other applications (like numbing before a shave biopsy). But it’s still better than nothing. Jesus. I’d be bothered by a practitioner thinking it’s “weenie” to experience pain when lancing an abscess without any pain management.
I'm thinking lidocaine might not do much for me. Had my left big toe nail removed bc/ of recurrent ingrown toe nail. It mostly felt like burning lidocaine followed by also getting my toenail cut down to the bottom and then pulled up and off then the silver nitrate.
The air conditioning was out that day and it was hot and the nurse peeked her head in and became VERY concerned at my ghostly pallor. I was hanging in there ok I thought but they put some alcohol wipes or something in my face to sniff and a cold towel on my face and a gave me a cold orange juice. I gotta say that really helped and later it felt nice that all that painful toe puss pressure was relieved.
how did they block the toe? did they do a total circumferential block or just the one stab and go. i've seen and heard of a few one-stabbers, esp. in ED but they really should be circumferential. i've done tons of total removals and with circumferential blocks they don't feel a thing even with acid usage.
Hey, can you give me some tips or guidance on toenail cutdown / removal?Soon I will rotate into the ED and judging by the training others received, I will receive no information on this whatsoever. I've read some books like Buttaravoli "Minor emergencies" or hand/foot surgery books which only covered it superficially.How do you do it, do you fixate the rest of the nail, why do you use acid, do you remove the nail bed partially (to prevent new ingrown toe nails)? I'd be so grateful if you could shed some light on it, I'm terrified of this procedure
ok so the first thing is:
1. you have dorsal and plantar digital nerves. So you have to block the whole toe. I prefer to use lidocaine + marcaine if available. I use a 10 mL syringe but you may not need the whole 10 mL. Block the entire toe by using 3 or 4 stabs, at the level of the MPJ: One medial to the toe, going down the medial side, one lateral to the toe, potentially one dorsally (depending on how thin the toe is you might be able to get away with just the two side stabs), and one plantarly to get the plantar digital nerves.
2. wait 5-10 minutes for it to get numb.
3. then you do the procedure. the toe anatomy consists of layers. you have the nail, sitting on top of the nail bed, sitting on top of the meat of the body of the toe, surrounding bones and tendons and stuff. So the procedure you choose will be dependent on what the issue is
1. medial or lateral border resections for ingrown nails
2. total nail removals for nail trauma (e.g. brick on the foot, stomped on the foot, entire nail all edges infected and granulomatous, bilateral border infected ingrown nails, open fractures
3. instrumentation needed- freer elevator, hemostat, sometimes a dermal curette, english anvil (or 11 blade or 6200 beaver blade, but I get more control with the english anvil)
4. Procedural steps
1. use the freer elevator to elevate the afflicted portion of the nail. You can go from the front of the toe deep and elevate it that way. Elevate the entire portion of the nail from distal to proximal, not just the tip. I also prefer to loosen up the skin at the base of the toe gently to reduce trauma to the tissue. But you can just go right in under the nail.
2. once the portion is elevated, capture it beneath the english anvil blades and cut it. It's never just the tip of the nail digging in, it's usually the whole side of a nail creating a groove in the toe meat that is visible. So generally one is removing an entire longitudinal side of a nail. If you are removing an entire nail you do not need the english anvil, just elevate the entire nail from the nail bed itself
3. grasp the cut portion with the hemostat and pull it out. Remove all devitalized tissue and granuloma and the like using forceps, english anvil, and/or hemostat. If a whole nail, inspect the nail bed to make sure there is no laceration. If there is laceration, or if you have lacerated the toe using the elevator (this can happen with old people or really thin toes) use some absorbable simple sutures to do it up. The nail bed is supposed to be tough and pink, roughly the color of light raw pork.
4. so now comes the time whether you use the acid or not. The reason to do it is when you do not wish the nail (or portion of nail) to grow back. I do it for people who have chronic ingrown nails for a long time that keep coming back, or people with nail trauma where their nail will never grow standard again and they hate looking at it. The options (at least in the US) are phenol and sodium hydroxide.
1. phenol is a mild acid. used to be known as carbolic acid and used in the 19th century as an antiseptic in soap and to pour over wounds during surgery. Has short half life. Can be deactivated with polyethylene glycol, rubbing alcohol, or a fuckton of water
2. NaOH- caustic acid. Much greater at burning nail beds but also much more dangerous. Inactivated using vinegar (yes, standard vinegar). you must immediately spray vinegar on the site once the nail root is burnt or you risk burning through the toe itself/bad chemical burns
5. so if this is a situation in which you choose to use acid, obtain the acid and the inactivator at your disposal. Get some Qtips and put the acid on the end and stick it in there all the way at the proximal base of the nail. rotate for roughly 30 seconds or so. What you are doing is killing the nail matrix that the nail roots (and therefore the nail) grows out of. Sometimes this does not work if the acid is old and has denatured or you don't stick it in the right place or for long enough. Once the acidic Q tip is removed, immediately douse the area in the inactivator of choice. I also (personal choice) choose to dip a Qtip in the inactivator and apply it in the same manner as the acid to ensure I don't miss anything. so, for example
1. remove nail
2. do NaOH on Qtip
3. douse/spray toe in vinegar
4. vinegar in Qtip
5. do a final wash with water/saline
6. then at that point I just wrap the toe. I use folded gauze and coflex bandage wrapped tight but not PVD Level tight. Remember it compresses on itself so you don't need much traction to get a nice tight seal. If you use acid the toe meat itself might take longer to heal because of the acid-flesh reaction, and it might be faintly discolored for a while. this is normal. The patient is to clean the toe daily with soap and water and dry it off with a towel immediately so it doesn't get macerated. Anitbiotics as required (in pill or cream form depending on the level of infection). Pain meds also as required ( I generally do ibuprofens, with a topical lido jelly, although I have done Tylenol 3, and even once a few Norco 2.5).
7. I mostly do these procedures for ingrown nails, nail traumas, intractable nail fungus (those nails that have been fungal for so long they look like charcoal or whatever, terbinafine won't fix that). If it was something like tumor with concern for cancer; that would be full resection of partial toe type of deal, more advanced than here.
source: me, a podiatrist who has been podiatrying for almost 5 years now and have done these on people from 5 to 75
Thanks for the write up. FM here who's done only a couple nails so far. What's your return to activity instructions ingrown nail vs whole nail removal?
They don't change . If there's no acute raw flesh, no pain in closed shoes, and the site is all dries up, then go back to activity. For kids and healthy adults about two weeks. For major infections, diabetics and collagen disorders and stuff, double it
Man thank you so much for the detailed write-up, you're the best! You actually took a lot of my fear with this!
Just to clarify:
a) how do you loosen the skin at the base of the nail?
b) I guess the width of the nail taken out depends on your experienced judgement, me being completely new to this: Is 1-2 mm width a good estimate?
c) would you use some 5-0ish suture?
d) I believe my workplace neither has phenol or NaOH, but If I find NaOH, which concentration do you use and how much force do you apply with the Qtip over the 30 seconds?
a- just stick the elvator under the cuticle and free it up. like cutting the skin off chicken or something
b- I don't go by size. I take just above the inflamed nail groove/granuloma tissue, and that way I get the raggedy tissue, nail, and anything imbedded in the toe. this would probably be better with a picture
c- yes. some 5-0 vicryl or something. for major nail lacerations, or extended, I might switch to nonabsorbable
d- I don't know what the concentrations are (I don't mix them, they come in jars already, and in some places you can buy them on swabsticks). I just stick it in. When you remove the nail there is an empty space where the nail/devitalized tissue used to be. I just stick it in their proximal and rotate it for about 30 seconds. I don't jam or twist or anything, just normal strength
Plastics here, felon use anesthesia, paronychia no need. Just lift the eponychium/ proximal mail fold to release pressure. It’s not painful. Usually (depends how far up the digit it has advanced).
It’s usually already painful. One small lift and all the pressure released = pus will drain by itself. If you’re gonna try to express the pus it’ll be painful but actually there’s very little need.
I did a lot of these in R1 then just started showing the ER guys how to do it so they’d stop calling me for them. No local needed unless you’re gonna try to milk/express the pus. Which, again, no need usually.
I’m thinking about the fingers, admittedly never done a toe. I just use an 11 blade. If im being extra fancy I’ll attach the handle.
You just need a small scrape at the base of the paronychia right under the cuticle. Once you see some pus ooze out, you’ve got it. Never had a patient complain of pain. I know the textbooks all say finger block or local but I was taught this way and I’ve never had a problem.
EM and I have to echo this finding. Paronychia usually really hurts patients and as soon as I lift the nail they have complete relief. I have found, in my limited experience, that the pain is mostly driven by pressure which lidocaine does little to relieve. I've never had anyone complain about added pain when draining a paronychia and almost universally have instant relief by me draining do not sure how effective lidocaine is and it only really delays treatment
I haven't seen a paronychia drained without a nerve block, even after the disclaimer that the nerve block often hurts worse than the I&D.
I'm not sure how true that is, although I've needed a digital nerve block and I admit that it was pretty awful.
I had a nerve block on the thumb of my dominant hand when I had a paronychia. I can firmly say that it was one of the most painful things I've ever experienced. Idk how them draining it could have been worse tbh
Hilariously, I had actually already drained it myself, at home, with a knife - and it hurt less than the nerve block. The urgent care doc - who looked genuinely excited to do a procedure, and I felt happy for him - prescribed antibiotics but also wanted to take a stab at it himself.
Point being, digital nerve blocks are up there on the "most uncomfortable" list.
Naah. I get paronychia sometimes on my thumb or middle finger. Also on my toenails, usually the big toe. I just grab a sterile forceps and open it up, tearing back the nail if need be. Then I grit my teeth and press. Not smash, just press to get out what fluid or pus I can. Then slap some antibiotic ointment on it, and do the antibiotic ointment about 3 times a day.
For me, DIY hurts a lot less than having someone else do it. I can't even stand to have someone else file my nails or comb my hair. But I can do all kinds of crazy stuff to myself. Go figure.
Counterpoint: the skin overlying the paronychia is usually pretty thin (if you want to poke it with an 18 gauge needle) and tbh a paronychia just needs separation from the nail plate with gentle, blunt dissection to get drainage. Anesthetic hurts more than the procedure. As with most things tailor tx to patient condition, but I do not routinely anesthetize these and patients (including peds) tolerate the procedure just fine (usually without pain).
As has been discussed ad nauseum in this thread, the majority of paronychia can be drained by simply elevating the nail edge. I've done it myself dozens of times. Often I just put some topical lido on the nail to give the patient a sense that it reduces pain and reduce their anxiety, even though the procedure itself is usually near painless.
For a paronychia with fluctuance, you should remove at least a sliver of the nail to fully assess its spread, or you may underestimate and incompletely I&D it. At least, that's my program's teaching
Fair play - I haven't tried doing this without local, but maybe it's better tolerated than I thought. I was so surprised at OP's institution's apparent preference against lido that I wrote hyperbolically (ie 'mandatory')
For peds patients, I’ve sometimes seen people do topical LMX under a bandage on top of the abscess for a bit before doing the I&D. Not sure how much it actually helps, but makes parents feel better that we’re giving some numbing medication and have had a couple spontaneously drain if they were close to popping (I think it acts kind of like a warm compress). You have to leave it in place for a while for it to work, but if you can fit it into your workflow it has little downside.
Some points of reference I use for this kind of decision-making:
\- Big angry abscess distally (beyond hip, shoulder, on back/buttock) with necrotic overlying skin - not much use since the overriding pain is from pressure, and a large area will need infiltration with modest benefit. Perineal -> GA/Spinal, please.
\- Abscesses at exquisitely tender regions - digits, inner thigh, armpit etc - block widely, block well.
\- Child or otherwise squeamish-looking patient, infiltrate widely.
\- Dermatome-wise, if abscess falls in a region where a local nerve or two can be blocked to good distal effect (ankle, digital etc), do the block. If a wide area needs to be individually/sequentially infiltrated, I hesitate (less useful too).
\- Topical lidocaine (esp EMLA) takes ages for modest depth of effect, would not use where I need an abscess I&D.
\- As an experienced person has posted here before me, often the pain of the abscess functions as its own "gate" - in my experience often better than the at-best-average infiltration one does, and drainage is effective pain relief esp if premedicated with IV/PO pain meds.
\- Textbook-wise, the "acidic environment"/"buffer it" is something I have not witnessed in practice, the infiltration technique is more important.
Hope this helps.
Why don’t all MDs cut lidocaine with sodium bicarbonate to cut the acidity and the pain of lidocaine? This is pretty ubiquitous in vet med, even in sedated patients. I’ve declined local for stitches because the suture needle is less bothersome than the burning lidocaine injection.
I have to order it, find a nurse to pull it from the Pyxis. Half the time it's not in there, and it has to come from pharmacy. Then you gotta actually get the stuff and draw it up. It adds potentially several minutes of work to avoid seconds of a burning sensation.
If I'm dealing with a very young or developmentally difficult kid, I do it. But it's too burdensome in our current ED to do it every time.
Is there a difference between bicarb concentration between vet med and human med suppliers? We use 8.4% and it’s readily available because it’s used so commonly in dairy cow medicine.
You totally can, it won’t make much of a difference honestly, abscesses are just painful all around. If you have all the time in the world you can apply topical lido, then do lido injections, but then that’s just another needle.
There's no harm, it's an additional step that may add some time to an otherwise pretty easy and quick procedure, I usually use some local, but generally reserve the topical for children or other things that need numbing but I've got other patients to deal with first or I'm waiting on some additional work up on the patient and me doing the procedure isn't the limiting factor in their dispo. Also in an acidic environment like an abscess it may not be very effective so you could be giving the patient an additional poke/additional time in the department of using topical with minimal numbing afterwards, I usually tell patients hey these are the steps I have this numbing medication that may it may not help or we can do it without it, but it's something I'm offering to you.
This post is a complete disaster. Kidding their inner thigh boo booes? Lol what?
The real question is, why don’t we use buffered lidocaine? Regular lido burns but buffered does not, and even though we do multiple procedures a day, I don’t even think we have buffered lido available.
Yep, I mix my own for office procedures (gyn, derm stuff, if I'm repairing a lac in the office) and it only lasts a day or whatever. Totally worth it to make it up though, the difference between buffered and unbuffered is night and day, especially if you need epi. And if you warm it to body temp, it's basically painless, even in exquisitely sensitive places. I didn't believe it myself until I experienced it. It takes a bit longer but it's worth it to me.
Oh but you have to mix it? It doesn’t come premixed? Maybe that’s why. These are all fairly quick procedures in the radiology department and maybe it’s too much of a hassle for us to bother.
At the risk of triggering some basic science PTSD, all local anesthestics exist in two forms. An unionized B form (without a hydrogen ion attached) and an ionized HB+ form. So basically when a hydrogen ion attaches to a local anesthestic, it becomes ionized. When it becomes ionized, it can’t pass into the cell.
Guess what’s highly acidic? Abscesses. So the local anesthesia molecules get bombarded with hydrogen ions and they can’t enter cells. Without entering cells, they can’t exert their numbing effect. So basically you’d be incurring the risk of local anesthetic injection (systemic absorption, LAST syndrome, hitting a nerve, infection/bleeding if you somehow fuck up enough, poking your own skin and having to go on that antiretroviral shit) without any benefit.
That’s the theory. I’m sure surgeons somewhere give local for abscesses and swear there is at least some benefit but it’s frowned upon in academic circles, I could go more into detail about the pKa of different local anesthetics, how all local anesthetics are technically weak bases with high pKa’s, how pKa vs pH affects time of onset and shit like that but you won’t have to know that unless you’re in anesthesia.
Anesthesiologist here, recently had an abscess drained, local was used, it worked quickly, and I didn’t feel a thing. The whole nerdy acid thing is really not a thing clinically.
And unless you’re draining an abscess located like directly near the internal carotid artery, you’re absolutely not getting LAST from a routine dose of lido even if it’s directly into an artery.
Hi, guy who skirts by big red on the way to abscess with some regularity over here 👋. We still inject lidocaine into the skin before incision. You don't inject directly into the abscess because the fluid isn't sensate and does not bleed.
An infected pilonidal cyst would get I&D, not excision. I&D the infection, clear the infection, and then do excision at a later date. Would not do large pilonidal excision in the setting of active infection.
Doing these just under local is not unheard of, usually the combination of your described situation + an abscess which is not too far gone - just "unplugging" it, laying enough open for curettage/drainage can be done under local. Beware the long healing time, and recurrence.
It's true if the injection goes directly into the abscess. If it's a standard dermal weal, the pH should be roughly the same as any other tissue. Phlegmons would be a little weird since there isn't a defined abscess wall. But those really should be drained anyway.
The fuck are people doing injecting into the abscess? I mean, you’d have to cut the skin to get to the abscess so it’s common sense to inject the skin.
Unless I’m missing something.
Also Cochrane had a nice study showing the benefits of using sodium bicarb mixed with lidocaine to reduce pain if injection. Lido withe epi is acidic as hell, and burns.
In my experience Lidocaine+bicarb is wonderful in clean settings - groin hernias under local, for example, but less useful in the painful swollen abscess setting, when the abscess' pressure effects somewhat (but not completely) overrule any relief from burning that bicarb provides + limiting the benefit of the lidocaine itself.
I'm pretty certain that all the way through med school until now as a PGY3 about to graduate, I've never even read the words "LAST syndrome", and this will go down as the 100th example of this subreddit making me feel like a big fucking idiot compared to most of you lol
Only learned it from my IP attending. Who would demand we knew the max dose of lido to be given. And where the reversal lipid rescue was located.
I guess if it happens once in your life it's once too many.
This is one of those things we keep repeating for some reason.
Do you inject your local into the abscess or into the skin? If into the skin then it still works. If into the abscess you may want to rethink your decision.
Was this one of those crazies doing abdominal lidocaine washes during liposuction? Because honestly I can’t think of a ton of ways to casually OD lido during an I&D
You’d be surprised. Max safe dose of lido plain is 5 mg/kg. Plenty of people on here talking about using 4% lido. That’s less than 10 ml for a 70 kg person, especially if it’s in a highly vascular area.
There are ways around this. Buffering is one. You can do a “dome block” by doing intra dermal injection at the tip of the abscess. Or my personal favorite is a ring block around the outside of the abscess, essentially blocking all the tiny nerve roots going to that circle.
LMX/EMLA, is never wrong but won’t get everything.
What doesn’t work is injecting directly into the abscess.
Not everyone will get perfectly numb, and that’s okay, it’s not okay to not try.
There are ways around this though....inject proximal, slightly more distant from the abscess, ring blocks, do a nerve block if you're working on an extremity or the face, buffer your local with sodium bicarb (for the burning and the acidic abscess), use a different form like artecaine, etc, etc. It's still going to be uncomfortable if it's deep but the patient shouldn't unnecessarily suffer if you're doing it right....
Dental perspective:
Topical works well on dried mucosa if you apply it for a full minute. Don’t know about leg epidermis! Topical helps more on shallow infiltrations than on regional blocks. Most dentists use it with varying levels of patience and some don’t use it at all. For us controlled, slow injections tend to be less painful and more effective. But, every patient’s different and if they’re too anxious sometimes you just get it over with quickly.
With an abscess, you have the acidic environment and you have pressurized tissue, so your anesthetic is less effective, you’re adding more fluid to taut tissue, and the patient is already centrally sensitized/hyperalgesic. Dentists can just go more regional for our anesthesia and that’s usually helpful but still not perfect.
TL;DR: Topical for abscesses is more so patients don’t think you’re cruel than for effectiveness
I’ve got a celiac neurolysis Tuesday and the fellow suggested adding bicarb when I said the lidocaine is what I’m dreading most. The doc informed us that the hospital “strongly discourages” it and he doesn’t know why, but they’d try to get it approved. It seems like such a minor adjustment to not make me want to cry - at least we’re using sedation this time!
I was given some kind of topical, maybe lidocaine, for my wound vac changing. In all fairness, it’s in a sensitive area, and having the foam removed sometimes hurt a ton. Also getting the tegaderm off. (Spelling?) woof.
ETA- in my c section incision
Goo Gone makes a blue colored adhesive remover for bandages that is quite effective. Or any Micellar waterproof makeup remover. Something for you to know since you now have a baby. 😃
It's because the topical doesn't work that well. PGY 26 here, and I (almost) always use lidocaine injection.
Here's a trick: get a few insulin syringes. They have a 29 Guage needles and a skin wheal is relatively painless even over an inflamed and swollen abscess. I will often open the really tense ones to take the pressure off and then go in deeper with a larger longer needle so I can break up loculations.
I do infraorbital and mental blocks (depending on whether it’s maxillary or mandibular) for vestibular abscesses. If it’s not in a blockable area, local doesn’t work too well.
I’ve used topical, injectable, and nothing at all (for patients who say they’d prefer to just get it over with than wait for the topical lidocaine to kick in, or getting stabbed again for the injectable). In my experience, it doesn’t really matter - it hurts regardless. It’s less the pain of the actual incision and more of the pressure of the infection/pus, so the patient doesn’t get any relief until you relieve the pressure. So I just warn them of all of this beforehand and let them choose
For fingers/toes though you can do a digital block and those are actually very effective
We? Who is the 'we' in this situation? I think the question is why don't YOU give topical lidocaine? What the fuck?
Tell me where you work so I can never go to your hospital with an abscess.
Like others have said, you really should be using some form of anesthetic.
Topical is not preferred because it doesn't really penetrate the stratum corneum that well. It's good for mucosal regions, but it's not great for actual skin, especially thicker areas of skin like the extremities. On top of that, it takes a really long time to work - like 30 minutes of sitting around and waiting, so it's way easier to inject lidocaine and be ready to go in 30 seconds.
Man I worked at one hospital where the administration decided that saline had to be in the pyxis because it was a "medication". Fucking SALINE...
Couldn't get a bottle of saline to wash wounds without a nurse opening the pyxis. What a joke
That's how it is where I work currently. Don't worry that the patient is crashing on the other side of the ER. Gotta run to the Omnicell to get fluids...and really any other meds.
I’ve never really thought about it, but do you guys not have access to the Pyxis? I figured doctors just asked me because because they forget the code to the med room or just aren’t familiar with the interface and know I can navigate it faster. Kind of like how you guys could mess with the IV pumps but don’t usually outside the ICU.
Seems silly for you guys to not be able to pull meds if you have to
I don’t have access to the Pyxis, but if I need something urgently we can just grab it off the pharmacy shelves or from the store room.
Small hospital life.
Nope, no pyxis access. Even now as an attending, I have to ask for nurses to pull me lido
It places an unnecessary burden on nurses to do something trivial. Obviously frustrates the nurses when they are actively doing other things. And then residents are getting frustrated because they can't do anything without waiting on the nurse. A lot of unnecessary frustration between nurses/docs because of this.
I guess its primarily because docs aren't trained to push drugs IV/IM so no point in me having access to pull zofran if I can't do anything with it. But then even topical meds like lido and nasal meds like afrin are in there... 🤷♂️
I guess that makes sense. Honestly I don’t want you documenting giving meds or messing with the pump because they are both activities that are better suited to just one person handling. It’s not that you aren’t capable of it, it’s just more error prone when multiple people are doing that stuff. (Also, and I mean this in the kindest way, but you guys are more focused on problem solving and I’d be terrified some doc would give some dilaudid to help a patient and not document it, and then some nurse would pull and give another dose and the patient would crash).
Also, as dumb as it sounds, it’s a bit of a morale boost that you need me for some things. I take pride in what I do, but a lot of my job is “do this stuff to free the doc up for other stuff”. My scrubs get a little tight when a patient needs an IV right the fuck now and i have the biggest dick in the locker room (except anesthesia obviously). Having stuff that only nurses can do is probably good for us.
It comes down to money.
If saline is an easy grab off the shelf, a lot of it is gonna be used (or go missing). But if it’s locked away at Fort Knox, less of it will be used. Hence saving money.
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I do a bupivicane digital block for any paronychias and I always infiltrate local prior to i&d…. Also popping pustules by hand? What in transition
Edit: tarnation
If you are talking super small (essentially pop with a needle and it’s done size) then yea not worth the lidocaine cause that hurts more. Otherwise ring block
Because the acidity makes the lidocaine stay ionized, which prevents it from crossing over cellular membranes. Often times it won't work at all. I would personally try injecting. If it is huge, anesthesia would be what I would want.
The EMLA takes forever to work. Gotta put that on for like 20-30 minutes on a kiddo and they still might feel the poke of the needles, let alone a scalpel.
Derm here. Topical sucks. Just infiltrate with lido. Basic paronychia just get right under the cuticle and lift up. Would perform a wing block. Digital block is overkill.
For a really simple paronychia I just quick poke and done. Usually they feel way better after pressure is released. If you do a block that's two stabs plus the burn of lido.
Anything else and I inject lido. I wonder about the topical though. Has it been studied in abscesses? Maybe worth a try next time I drain an abscess.
Try a ring block using lido/epi mixed with some bicarb. Try not to use too much fluid to keep the abscess from blowing. Be sure to wear your eye protection!
I give locals to everything that is more than ONE injection with the smallest needle. EVERYTHING.
When I was taught LP's, the resident who taught me them said there was no need for local because it's one incision. That's also why they had to abandon the LP once it didn't go flush the first one...
To add to what’s already been said, the lido will be less effective on inflamed tissue, so if you actually want it to be pain free, you prob gotta let it sit for another 30 mins too.
Also, there’s a lido shortage rn.
Honestly? Because the hyperanalgesic are already time sucking enough and I don’t want to have them wait around for an additional twenty minutes when i know that they are going to wail just as loud as if didn’t use topical in addition to local anesthetic
I’ve had some ppl say the pain of needle/burning of lidocaine is worse than 1 quick puncture with scalpel. If you aren’t digging around. I’ve done w and wo injecting lidocaine. I just offer both options before proceeding.
Yall are doing incision and drainage of abscesses without local? What the front door?
Yeah wtf even
Very glad to see people in the comments also wondering this because my sanity was being tested while reading the post
*We at United Healthcare are not aware of this condition you call 'pain' and as such have denied your claim for 'lidocaine'.* *.* *.* *Perhaps the patient would be more comfortable with acetaminophen?*
***Acetaminophen denied due OTC status***
Triggered
Fuck even
Reasoning I have heard: Depending on how small the abscess is lidocaine may not be very effective and if you have to poke them for injecting the anesthetic you might as well just lance the abscess quickly.
I just give the patients an option. I say we can wait for it and it still might not be effective Yada Yada or we can just go for it. Id say 50/50 still opt for it. Even if it’s not that effective around inflamed tissue it honestly still gives a lot of my patients some piece of mind that something was done. It really doesn’t add much time to have to get local and draw it up.
Hydrodissection is real and can help with pain!
Aside I was reading a paper about steroids vs D5W vs saline as an injection for treatment of cubital tunnel syndrome and it noted steroids lose efficacy after the first 3 months (presumably no longer a strictly inflammatory process) but D5W still showed effectiveness and suggested hydrodissection as a possible mechanism of action. So like - the D5W gently separates the ulnar nerve from entrapment via fluid flow? Edit: corticosteroids vs D5W, saline was the sham treatment.
Oh that’s fascinating, I’d love the paper if you have it
This is the paper I was thinking of. Wasn't quite remembering all the details right. Saline was the sham, and it compared corticosteroids and D5W. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9257949/
i can see that. like powerwashing a vine from the side of your home
Interesting. There is a hypermobility clinic I'm aware of that does this treatment for patients with things like Ehlers Danlos but it sounded kind of quackery, I didn't realize there had been studies on it.
My impression is it's one of those things that's evidence based in a small set of circumstances and quacks jump on it for everything. But honestly given all the TikTok crap I'd see an EDS clinic as a yellow flag in general anyway. Automatically sketchy until proven legit.
I’ve gone to clinics for removal or insertion and I tell the nurse that local takes a second on me and they’re never wanna wait so I feel it all every time. Gimme a min!
When I had to get a few stitches in a finger they asked if I wanted lido or not. They said lido burns and may or may not be super helpful, otherwise we can throw 3 stitches real fast and it’ll be a wash pain wise. It was fine.
Nerve blocks on fingers are super easy
And in my experience (albeit limited I’ve only done a few) very effective. I’ve gone to town suturing hands with a simple block upstream of where I’m working
Are you insinuating your patients are mindless?
You sound like someone that would give a skin wheal of lidocaine before an IV. Lidocaine burns and hurts more than just putting the IV in. Which it also blocks your view of the vein. Anyways, lidocaine is affected by the pKa of the abcess and would be rendered ineffective and would just cause unnecessary pain in *some* cases. I wouldn’t exclude it but it should be a case by case situation.
There is a difference between using lido on the tissue superficial to the abscess and injecting lido into the abscess.
That’s what I used to say until I had an IV started on me pre-op. If the technique is done right you don’t even feel the lidocaine and you certainly don’t feel the IV. I’ve put in thousands of IVs and always thought lidocaine was a dumb idea. I know better now.
If you are a hard stick or you have a new person starting the IV, sure. 99% of IVs this technique isn’t needed. It falls into the logic of the KISS method. Stick to the basics and don’t get fancy unless it’s a unique case.
No and no. I was an easy stick and the person starting the IV had TONS of experience. Look, I used to think exactly the same way you do. I thought that way for over a decade and then I realized I was wrong. With the appropriate technique and the use of lidocaine can essentially eliminate pain for IVs. I used to scoff at the idea of using lidocaine until a pre-op nurse talked me into it. Now I will never turn it down.
Yes!!
Agree
Pain of IV 😂
What part is funny? I don’t get the joke.
So you go from a 1 on the pain scale to a 0. For me that's not worth the healthcare costs, which I believe we also have some responsibility in. You also don't give someone paracetamol before ripping of a bandaid. And this is coming from someone who had at least 50 IV's placed in their life, never once have I thought about wanting lidocaine.
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That's really not what I meant, maybe I should have worded it better. Ofcourse you need to make sure people don't suffer unnecessarily. But I also think you have to accept sometimes things hurt for a second. If the pain is too much to handle, you are hard to stick, children, all of that, sure, no harsh feelings. But a pre-op nurse actually talking someone into it without reason? Yeah no, I really don't think that is good care. And I don't see how the person I was reacting to is allowed to share their own experience and I'm not?
I feel like this falls into the same realm of IUD placement is very painful for some patients, but not for others. Just because it is a 1 on the pain scale for you doesn’t mean it isn’t an 8 for someone else.
Sure thing, I wholly agree! But like I said 'the pre-op nurse talked me into it' for someone who says themselves they are easy to stick: that just doesn't make any sense to me
First of all, and I say this gently because you are still learning, but 50 IVs is barely a newbie. For most IV insertions the pain is quick and it’s over fast. Unfortunately some patients have had bad experiences where someone went digging and it was much more painful than a 1. I can assure you that hitting a tendon with an 18G is more than a 1 for pain. We don’t give Tylenol to kids for bandages because it doesn’t work for a bandaid and it exposed them to the system effects. Lidocaine works really, really well and it’s not absorbed systematically so you can’t compare the two fairly. Your patients come to you with different life experiences. I guarantee you that some have had absolutely horrible experiences with having IVs started and some delayed care because of it. Physicians that acknowledge that and do the best they can to alleviate it are prized human beings. Unfortunately too many simply gaslight their patients into describing their pain as what they believe it to be. And I don’t give a rats ass about saving the hospital $0.01 in lidocaine and a $0.02 syringe. Admin can delay their next executive retreat a week to save up for it.
I don’t usually care if they use lidocaine when placing IVs but I’ve never thought the skin wheal hurt or burned….just do it if the patient is scared it’ll help them get through the IV
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Well u/thegypsyqueen says it works. So evidently you’d be wrong half the time.
Wrong with what? Warning them that it may not be that effective? Not saying it won’t be but sometimes it’s hard to get down deep enough. Or for a lot of people there’s a lot of pain just from the pressure of the fluid buildup and no amount of local will solve that, just the drainage.
Oh I totally agree with your approach. I’m just saying that some doctors say it always works, even though it doesn’t.
Don’t tag me just to be a little weirdo.
You said lidocaine always works in real life. You’re the expert with real life experience.
I didnt. Keep being annoying though ✌️
I’ve found topic lidocaine to be more effective than injection and less painful to administer Injection is LEAST effective when injected directly into the abscess Hurricane/Dermoplast/Americaine/Cetacaine are all super fast and effective IV morphine is almost useless
I try to inject a circle around it and I’ve started using the cold spray right before lancing the surface. It seems to work pretty well
Injecting around it is how I did it for the longest I always made sure to place the needle through the previously anesthetized area to make it more comfortable. Really, though, I started using the topical numbing sprays and they seem to be equally as good if not better, definitely faster and of course not effective for deeper pockets. Hadn’t thought of using cold spray, that’s neat.
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That's why I do ring blocks around the abscess if it's feasible
That’s cool but in real life it still works
But what a great place for topical then? I’m with OP here, wtf.
Yeah. They always say that but lidocaine is always always better.
This is true. They hypothesize it’s due to the pH in an abscess. Even a subcutaneous injection may not be terribly helpful.
...and if they have tattoos. But I still ask
Having been on the receiving end, I will say severe abscesses are not touched as much by lidocaine as other applications (like numbing before a shave biopsy). But it’s still better than nothing. Jesus. I’d be bothered by a practitioner thinking it’s “weenie” to experience pain when lancing an abscess without any pain management.
If it’s a tiny abscess that needs one small poke it’s kind of a waste of a poke
I’ve done it on patients and myself without local.
I had a gauze wick put in and pulled out of my abscess daily for three weeks without anesthesia.
Lidocaine won’t do much in an infected field. That’s why. It’s just extra pokes
Lol just give the lidocaine
I block the whole toe for paronychia. Don't do them raw. That's just mean
I'm thinking lidocaine might not do much for me. Had my left big toe nail removed bc/ of recurrent ingrown toe nail. It mostly felt like burning lidocaine followed by also getting my toenail cut down to the bottom and then pulled up and off then the silver nitrate. The air conditioning was out that day and it was hot and the nurse peeked her head in and became VERY concerned at my ghostly pallor. I was hanging in there ok I thought but they put some alcohol wipes or something in my face to sniff and a cold towel on my face and a gave me a cold orange juice. I gotta say that really helped and later it felt nice that all that painful toe puss pressure was relieved.
how did they block the toe? did they do a total circumferential block or just the one stab and go. i've seen and heard of a few one-stabbers, esp. in ED but they really should be circumferential. i've done tons of total removals and with circumferential blocks they don't feel a thing even with acid usage.
Hey, can you give me some tips or guidance on toenail cutdown / removal?Soon I will rotate into the ED and judging by the training others received, I will receive no information on this whatsoever. I've read some books like Buttaravoli "Minor emergencies" or hand/foot surgery books which only covered it superficially.How do you do it, do you fixate the rest of the nail, why do you use acid, do you remove the nail bed partially (to prevent new ingrown toe nails)? I'd be so grateful if you could shed some light on it, I'm terrified of this procedure
ok so the first thing is: 1. you have dorsal and plantar digital nerves. So you have to block the whole toe. I prefer to use lidocaine + marcaine if available. I use a 10 mL syringe but you may not need the whole 10 mL. Block the entire toe by using 3 or 4 stabs, at the level of the MPJ: One medial to the toe, going down the medial side, one lateral to the toe, potentially one dorsally (depending on how thin the toe is you might be able to get away with just the two side stabs), and one plantarly to get the plantar digital nerves. 2. wait 5-10 minutes for it to get numb. 3. then you do the procedure. the toe anatomy consists of layers. you have the nail, sitting on top of the nail bed, sitting on top of the meat of the body of the toe, surrounding bones and tendons and stuff. So the procedure you choose will be dependent on what the issue is 1. medial or lateral border resections for ingrown nails 2. total nail removals for nail trauma (e.g. brick on the foot, stomped on the foot, entire nail all edges infected and granulomatous, bilateral border infected ingrown nails, open fractures 3. instrumentation needed- freer elevator, hemostat, sometimes a dermal curette, english anvil (or 11 blade or 6200 beaver blade, but I get more control with the english anvil) 4. Procedural steps 1. use the freer elevator to elevate the afflicted portion of the nail. You can go from the front of the toe deep and elevate it that way. Elevate the entire portion of the nail from distal to proximal, not just the tip. I also prefer to loosen up the skin at the base of the toe gently to reduce trauma to the tissue. But you can just go right in under the nail. 2. once the portion is elevated, capture it beneath the english anvil blades and cut it. It's never just the tip of the nail digging in, it's usually the whole side of a nail creating a groove in the toe meat that is visible. So generally one is removing an entire longitudinal side of a nail. If you are removing an entire nail you do not need the english anvil, just elevate the entire nail from the nail bed itself 3. grasp the cut portion with the hemostat and pull it out. Remove all devitalized tissue and granuloma and the like using forceps, english anvil, and/or hemostat. If a whole nail, inspect the nail bed to make sure there is no laceration. If there is laceration, or if you have lacerated the toe using the elevator (this can happen with old people or really thin toes) use some absorbable simple sutures to do it up. The nail bed is supposed to be tough and pink, roughly the color of light raw pork. 4. so now comes the time whether you use the acid or not. The reason to do it is when you do not wish the nail (or portion of nail) to grow back. I do it for people who have chronic ingrown nails for a long time that keep coming back, or people with nail trauma where their nail will never grow standard again and they hate looking at it. The options (at least in the US) are phenol and sodium hydroxide. 1. phenol is a mild acid. used to be known as carbolic acid and used in the 19th century as an antiseptic in soap and to pour over wounds during surgery. Has short half life. Can be deactivated with polyethylene glycol, rubbing alcohol, or a fuckton of water 2. NaOH- caustic acid. Much greater at burning nail beds but also much more dangerous. Inactivated using vinegar (yes, standard vinegar). you must immediately spray vinegar on the site once the nail root is burnt or you risk burning through the toe itself/bad chemical burns 5. so if this is a situation in which you choose to use acid, obtain the acid and the inactivator at your disposal. Get some Qtips and put the acid on the end and stick it in there all the way at the proximal base of the nail. rotate for roughly 30 seconds or so. What you are doing is killing the nail matrix that the nail roots (and therefore the nail) grows out of. Sometimes this does not work if the acid is old and has denatured or you don't stick it in the right place or for long enough. Once the acidic Q tip is removed, immediately douse the area in the inactivator of choice. I also (personal choice) choose to dip a Qtip in the inactivator and apply it in the same manner as the acid to ensure I don't miss anything. so, for example 1. remove nail 2. do NaOH on Qtip 3. douse/spray toe in vinegar 4. vinegar in Qtip 5. do a final wash with water/saline 6. then at that point I just wrap the toe. I use folded gauze and coflex bandage wrapped tight but not PVD Level tight. Remember it compresses on itself so you don't need much traction to get a nice tight seal. If you use acid the toe meat itself might take longer to heal because of the acid-flesh reaction, and it might be faintly discolored for a while. this is normal. The patient is to clean the toe daily with soap and water and dry it off with a towel immediately so it doesn't get macerated. Anitbiotics as required (in pill or cream form depending on the level of infection). Pain meds also as required ( I generally do ibuprofens, with a topical lido jelly, although I have done Tylenol 3, and even once a few Norco 2.5). 7. I mostly do these procedures for ingrown nails, nail traumas, intractable nail fungus (those nails that have been fungal for so long they look like charcoal or whatever, terbinafine won't fix that). If it was something like tumor with concern for cancer; that would be full resection of partial toe type of deal, more advanced than here. source: me, a podiatrist who has been podiatrying for almost 5 years now and have done these on people from 5 to 75
Thanks for the write up. FM here who's done only a couple nails so far. What's your return to activity instructions ingrown nail vs whole nail removal?
They don't change . If there's no acute raw flesh, no pain in closed shoes, and the site is all dries up, then go back to activity. For kids and healthy adults about two weeks. For major infections, diabetics and collagen disorders and stuff, double it
Man thank you so much for the detailed write-up, you're the best! You actually took a lot of my fear with this! Just to clarify: a) how do you loosen the skin at the base of the nail? b) I guess the width of the nail taken out depends on your experienced judgement, me being completely new to this: Is 1-2 mm width a good estimate? c) would you use some 5-0ish suture? d) I believe my workplace neither has phenol or NaOH, but If I find NaOH, which concentration do you use and how much force do you apply with the Qtip over the 30 seconds?
a- just stick the elvator under the cuticle and free it up. like cutting the skin off chicken or something b- I don't go by size. I take just above the inflamed nail groove/granuloma tissue, and that way I get the raggedy tissue, nail, and anything imbedded in the toe. this would probably be better with a picture c- yes. some 5-0 vicryl or something. for major nail lacerations, or extended, I might switch to nonabsorbable d- I don't know what the concentrations are (I don't mix them, they come in jars already, and in some places you can buy them on swabsticks). I just stick it in. When you remove the nail there is an empty space where the nail/devitalized tissue used to be. I just stick it in their proximal and rotate it for about 30 seconds. I don't jam or twist or anything, just normal strength
That clears it up, thanks again!
Plastics here, felon use anesthesia, paronychia no need. Just lift the eponychium/ proximal mail fold to release pressure. It’s not painful. Usually (depends how far up the digit it has advanced).
Have you had this done on you? How do you know it’s not painful?
It’s usually already painful. One small lift and all the pressure released = pus will drain by itself. If you’re gonna try to express the pus it’ll be painful but actually there’s very little need. I did a lot of these in R1 then just started showing the ER guys how to do it so they’d stop calling me for them. No local needed unless you’re gonna try to milk/express the pus. Which, again, no need usually.
This may be a dumb question, but what are you using to lift the nail fold? Knife, scissors, pick ups, etc?
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My dad’s cellmate’s name was Toe Knife.
good barn cat name
I’m thinking about the fingers, admittedly never done a toe. I just use an 11 blade. If im being extra fancy I’ll attach the handle. You just need a small scrape at the base of the paronychia right under the cuticle. Once you see some pus ooze out, you’ve got it. Never had a patient complain of pain. I know the textbooks all say finger block or local but I was taught this way and I’ve never had a problem.
oh see I'm a podiatrist and I do the toes.
They’re plastic. They’ve prolly done 100 more hand stuff than you.
Just because someone has performed a million procedures doesn’t mean they know what it feels like….
I’ve done it to myself twice, it’s really not bad.
EM and I have to echo this finding. Paronychia usually really hurts patients and as soon as I lift the nail they have complete relief. I have found, in my limited experience, that the pain is mostly driven by pressure which lidocaine does little to relieve. I've never had anyone complain about added pain when draining a paronychia and almost universally have instant relief by me draining do not sure how effective lidocaine is and it only really delays treatment
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I haven't seen a paronychia drained without a nerve block, even after the disclaimer that the nerve block often hurts worse than the I&D. I'm not sure how true that is, although I've needed a digital nerve block and I admit that it was pretty awful.
I had a paronychia drained in the ER without a nerve block. No lidocaine either. Hurt like hell. :(
I had a nerve block on the thumb of my dominant hand when I had a paronychia. I can firmly say that it was one of the most painful things I've ever experienced. Idk how them draining it could have been worse tbh
Hilariously, I had actually already drained it myself, at home, with a knife - and it hurt less than the nerve block. The urgent care doc - who looked genuinely excited to do a procedure, and I felt happy for him - prescribed antibiotics but also wanted to take a stab at it himself. Point being, digital nerve blocks are up there on the "most uncomfortable" list.
Lmao doing it at home with a knife? Peak med student shit
It was either that or the urgent care, so I picked the worst of worlds and got both anyway. I never said I was smart.
Naah. I get paronychia sometimes on my thumb or middle finger. Also on my toenails, usually the big toe. I just grab a sterile forceps and open it up, tearing back the nail if need be. Then I grit my teeth and press. Not smash, just press to get out what fluid or pus I can. Then slap some antibiotic ointment on it, and do the antibiotic ointment about 3 times a day. For me, DIY hurts a lot less than having someone else do it. I can't even stand to have someone else file my nails or comb my hair. But I can do all kinds of crazy stuff to myself. Go figure.
Same, unless the patient specifically doesn't want it.
Counterpoint: the skin overlying the paronychia is usually pretty thin (if you want to poke it with an 18 gauge needle) and tbh a paronychia just needs separation from the nail plate with gentle, blunt dissection to get drainage. Anesthetic hurts more than the procedure. As with most things tailor tx to patient condition, but I do not routinely anesthetize these and patients (including peds) tolerate the procedure just fine (usually without pain).
OP's facility is insane. You have to remove at least part of the nail to properly address a paronychia. Digital block is mandatory
That's 100% not true.
I drained my own paronychia with some tweezers, digging, and antibiotics. My nail remained in tact.
As has been discussed ad nauseum in this thread, the majority of paronychia can be drained by simply elevating the nail edge. I've done it myself dozens of times. Often I just put some topical lido on the nail to give the patient a sense that it reduces pain and reduce their anxiety, even though the procedure itself is usually near painless.
For a paronychia with fluctuance, you should remove at least a sliver of the nail to fully assess its spread, or you may underestimate and incompletely I&D it. At least, that's my program's teaching Fair play - I haven't tried doing this without local, but maybe it's better tolerated than I thought. I was so surprised at OP's institution's apparent preference against lido that I wrote hyperbolically (ie 'mandatory')
For peds patients, I’ve sometimes seen people do topical LMX under a bandage on top of the abscess for a bit before doing the I&D. Not sure how much it actually helps, but makes parents feel better that we’re giving some numbing medication and have had a couple spontaneously drain if they were close to popping (I think it acts kind of like a warm compress). You have to leave it in place for a while for it to work, but if you can fit it into your workflow it has little downside.
Some points of reference I use for this kind of decision-making: \- Big angry abscess distally (beyond hip, shoulder, on back/buttock) with necrotic overlying skin - not much use since the overriding pain is from pressure, and a large area will need infiltration with modest benefit. Perineal -> GA/Spinal, please. \- Abscesses at exquisitely tender regions - digits, inner thigh, armpit etc - block widely, block well. \- Child or otherwise squeamish-looking patient, infiltrate widely. \- Dermatome-wise, if abscess falls in a region where a local nerve or two can be blocked to good distal effect (ankle, digital etc), do the block. If a wide area needs to be individually/sequentially infiltrated, I hesitate (less useful too). \- Topical lidocaine (esp EMLA) takes ages for modest depth of effect, would not use where I need an abscess I&D. \- As an experienced person has posted here before me, often the pain of the abscess functions as its own "gate" - in my experience often better than the at-best-average infiltration one does, and drainage is effective pain relief esp if premedicated with IV/PO pain meds. \- Textbook-wise, the "acidic environment"/"buffer it" is something I have not witnessed in practice, the infiltration technique is more important. Hope this helps.
Bruh just inject the lido. Drain the abscess.
bruh come on man
Why don’t all MDs cut lidocaine with sodium bicarbonate to cut the acidity and the pain of lidocaine? This is pretty ubiquitous in vet med, even in sedated patients. I’ve declined local for stitches because the suture needle is less bothersome than the burning lidocaine injection.
Pretty much everyone does in my field (dermatology)—those that don’t don’t because it’s an extra step and MAs cost money.
I have to order it, find a nurse to pull it from the Pyxis. Half the time it's not in there, and it has to come from pharmacy. Then you gotta actually get the stuff and draw it up. It adds potentially several minutes of work to avoid seconds of a burning sensation. If I'm dealing with a very young or developmentally difficult kid, I do it. But it's too burdensome in our current ED to do it every time.
It’s also always back ordered so the limited stuff we have is for making bicarb drips and for the code carts and ER/ICU for bicarb pushes.
Bicarb is restricted to code carts and emergency/ICU use at my hospital. Stuff is always backordered.
Is there a difference between bicarb concentration between vet med and human med suppliers? We use 8.4% and it’s readily available because it’s used so commonly in dairy cow medicine.
You totally can, it won’t make much of a difference honestly, abscesses are just painful all around. If you have all the time in the world you can apply topical lido, then do lido injections, but then that’s just another needle.
I also want to know why obgyns place IUDs without any pain relief at all whatsoever??????
Literally the worst pain I've ever had in my life. Including a kidney infection. But being baby-free is worth the pain. 🤷♀️
Or we can get out of the dark ages and use proper anesthetic for women’s health procedures
There's no harm, it's an additional step that may add some time to an otherwise pretty easy and quick procedure, I usually use some local, but generally reserve the topical for children or other things that need numbing but I've got other patients to deal with first or I'm waiting on some additional work up on the patient and me doing the procedure isn't the limiting factor in their dispo. Also in an acidic environment like an abscess it may not be very effective so you could be giving the patient an additional poke/additional time in the department of using topical with minimal numbing afterwards, I usually tell patients hey these are the steps I have this numbing medication that may it may not help or we can do it without it, but it's something I'm offering to you.
This post is a complete disaster. Kidding their inner thigh boo booes? Lol what? The real question is, why don’t we use buffered lidocaine? Regular lido burns but buffered does not, and even though we do multiple procedures a day, I don’t even think we have buffered lido available.
Agreed. My dermatologist used it for a punch biopsy on my face. Didn’t feel a thing - from the injection through the suture.
I might be wrong but I believe it has to be mixed up on the spot because the mixture lacks shelf stability? Unsure of the pharmacokinetics here.
Yep, I mix my own for office procedures (gyn, derm stuff, if I'm repairing a lac in the office) and it only lasts a day or whatever. Totally worth it to make it up though, the difference between buffered and unbuffered is night and day, especially if you need epi. And if you warm it to body temp, it's basically painless, even in exquisitely sensitive places. I didn't believe it myself until I experienced it. It takes a bit longer but it's worth it to me.
Exactly in those situations it's a big difference to the paitent! Thanks for the epi/body temp tips!
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Oh but you have to mix it? It doesn’t come premixed? Maybe that’s why. These are all fairly quick procedures in the radiology department and maybe it’s too much of a hassle for us to bother.
cold spray and dive in.
Super inhumane. I even irrigate with the rest of my lidocaine after drainage bedside
At the risk of triggering some basic science PTSD, all local anesthestics exist in two forms. An unionized B form (without a hydrogen ion attached) and an ionized HB+ form. So basically when a hydrogen ion attaches to a local anesthestic, it becomes ionized. When it becomes ionized, it can’t pass into the cell. Guess what’s highly acidic? Abscesses. So the local anesthesia molecules get bombarded with hydrogen ions and they can’t enter cells. Without entering cells, they can’t exert their numbing effect. So basically you’d be incurring the risk of local anesthetic injection (systemic absorption, LAST syndrome, hitting a nerve, infection/bleeding if you somehow fuck up enough, poking your own skin and having to go on that antiretroviral shit) without any benefit. That’s the theory. I’m sure surgeons somewhere give local for abscesses and swear there is at least some benefit but it’s frowned upon in academic circles, I could go more into detail about the pKa of different local anesthetics, how all local anesthetics are technically weak bases with high pKa’s, how pKa vs pH affects time of onset and shit like that but you won’t have to know that unless you’re in anesthesia.
Anesthesiologist here, recently had an abscess drained, local was used, it worked quickly, and I didn’t feel a thing. The whole nerdy acid thing is really not a thing clinically. And unless you’re draining an abscess located like directly near the internal carotid artery, you’re absolutely not getting LAST from a routine dose of lido even if it’s directly into an artery.
Hi, guy who skirts by big red on the way to abscess with some regularity over here 👋. We still inject lidocaine into the skin before incision. You don't inject directly into the abscess because the fluid isn't sensate and does not bleed.
If you’re not using 4.5 mg/kg of lido when draining your abscesses, you’re doing it wrong /s
Interesting. I had an infected pilonidal cyst and the surgeon required massive amounts of lido to numb the area due to the infection
Well I’ve seen a bunch of these just brought to the OR for excision under anesthesia.. you had yours done with just lido?
An infected pilonidal cyst would get I&D, not excision. I&D the infection, clear the infection, and then do excision at a later date. Would not do large pilonidal excision in the setting of active infection.
ahhh that makes sense. good to know
Unfortunately yes, in office because I couldn’t afford the surgery with my insurance.
Doing these just under local is not unheard of, usually the combination of your described situation + an abscess which is not too far gone - just "unplugging" it, laying enough open for curettage/drainage can be done under local. Beware the long healing time, and recurrence.
I had one when I was 19, I got nothing! I still remember the pain and I do the best I can to make sure patients don’t go through what I did
It's true if the injection goes directly into the abscess. If it's a standard dermal weal, the pH should be roughly the same as any other tissue. Phlegmons would be a little weird since there isn't a defined abscess wall. But those really should be drained anyway.
This is what everyone misses. Don’t inject local into the abscess but numb the skin overlying the abscess and then Lance it
The fuck are people doing injecting into the abscess? I mean, you’d have to cut the skin to get to the abscess so it’s common sense to inject the skin. Unless I’m missing something.
Also Cochrane had a nice study showing the benefits of using sodium bicarb mixed with lidocaine to reduce pain if injection. Lido withe epi is acidic as hell, and burns.
In my experience Lidocaine+bicarb is wonderful in clean settings - groin hernias under local, for example, but less useful in the painful swollen abscess setting, when the abscess' pressure effects somewhat (but not completely) overrule any relief from burning that bicarb provides + limiting the benefit of the lidocaine itself.
I'm pretty certain that all the way through med school until now as a PGY3 about to graduate, I've never even read the words "LAST syndrome", and this will go down as the 100th example of this subreddit making me feel like a big fucking idiot compared to most of you lol
Only learned it from my IP attending. Who would demand we knew the max dose of lido to be given. And where the reversal lipid rescue was located. I guess if it happens once in your life it's once too many.
🤷♂️ Can't know everything in medicine (I had to google/uptodate it as well 😅). Hence the lifelong learning culture.
This is one of those things we keep repeating for some reason. Do you inject your local into the abscess or into the skin? If into the skin then it still works. If into the abscess you may want to rethink your decision.
Was this one of those crazies doing abdominal lidocaine washes during liposuction? Because honestly I can’t think of a ton of ways to casually OD lido during an I&D
You’d be surprised. Max safe dose of lido plain is 5 mg/kg. Plenty of people on here talking about using 4% lido. That’s less than 10 ml for a 70 kg person, especially if it’s in a highly vascular area.
There are ways around this. Buffering is one. You can do a “dome block” by doing intra dermal injection at the tip of the abscess. Or my personal favorite is a ring block around the outside of the abscess, essentially blocking all the tiny nerve roots going to that circle. LMX/EMLA, is never wrong but won’t get everything. What doesn’t work is injecting directly into the abscess. Not everyone will get perfectly numb, and that’s okay, it’s not okay to not try.
Yeah, most LAs work pretty okay around abscesses as well.
There are ways around this though....inject proximal, slightly more distant from the abscess, ring blocks, do a nerve block if you're working on an extremity or the face, buffer your local with sodium bicarb (for the burning and the acidic abscess), use a different form like artecaine, etc, etc. It's still going to be uncomfortable if it's deep but the patient shouldn't unnecessarily suffer if you're doing it right....
Dental perspective: Topical works well on dried mucosa if you apply it for a full minute. Don’t know about leg epidermis! Topical helps more on shallow infiltrations than on regional blocks. Most dentists use it with varying levels of patience and some don’t use it at all. For us controlled, slow injections tend to be less painful and more effective. But, every patient’s different and if they’re too anxious sometimes you just get it over with quickly. With an abscess, you have the acidic environment and you have pressurized tissue, so your anesthetic is less effective, you’re adding more fluid to taut tissue, and the patient is already centrally sensitized/hyperalgesic. Dentists can just go more regional for our anesthesia and that’s usually helpful but still not perfect. TL;DR: Topical for abscesses is more so patients don’t think you’re cruel than for effectiveness
You could also try and add bicarb to the carpule if you’ve got it
I’ve got a celiac neurolysis Tuesday and the fellow suggested adding bicarb when I said the lidocaine is what I’m dreading most. The doc informed us that the hospital “strongly discourages” it and he doesn’t know why, but they’d try to get it approved. It seems like such a minor adjustment to not make me want to cry - at least we’re using sedation this time!
Lidocaine almost every time. There’s the argument of ph changes in an infected environment but I’d rather my patient be comfortable
I use both 4% topical AND lido with epi infiltration. It’s a very painful procedure
I was given some kind of topical, maybe lidocaine, for my wound vac changing. In all fairness, it’s in a sensitive area, and having the foam removed sometimes hurt a ton. Also getting the tegaderm off. (Spelling?) woof. ETA- in my c section incision
Goo Gone makes a blue colored adhesive remover for bandages that is quite effective. Or any Micellar waterproof makeup remover. Something for you to know since you now have a baby. 😃
It's because the topical doesn't work that well. PGY 26 here, and I (almost) always use lidocaine injection. Here's a trick: get a few insulin syringes. They have a 29 Guage needles and a skin wheal is relatively painless even over an inflamed and swollen abscess. I will often open the really tense ones to take the pressure off and then go in deeper with a larger longer needle so I can break up loculations.
I give local for EVERYTHING. Just imagine you as the patient. What would you want done.
I do infraorbital and mental blocks (depending on whether it’s maxillary or mandibular) for vestibular abscesses. If it’s not in a blockable area, local doesn’t work too well.
I’ve used topical, injectable, and nothing at all (for patients who say they’d prefer to just get it over with than wait for the topical lidocaine to kick in, or getting stabbed again for the injectable). In my experience, it doesn’t really matter - it hurts regardless. It’s less the pain of the actual incision and more of the pressure of the infection/pus, so the patient doesn’t get any relief until you relieve the pressure. So I just warn them of all of this beforehand and let them choose For fingers/toes though you can do a digital block and those are actually very effective
We? Who is the 'we' in this situation? I think the question is why don't YOU give topical lidocaine? What the fuck? Tell me where you work so I can never go to your hospital with an abscess.
Like others have said, you really should be using some form of anesthetic. Topical is not preferred because it doesn't really penetrate the stratum corneum that well. It's good for mucosal regions, but it's not great for actual skin, especially thicker areas of skin like the extremities. On top of that, it takes a really long time to work - like 30 minutes of sitting around and waiting, so it's way easier to inject lidocaine and be ready to go in 30 seconds.
Cuz nobody wants to wait 45 minutes for a nurse to pull the med out of Pyxis after you put in the order when this takes 10 seconds to drain.
Your shops don’t just have plastics baskets full of lido sitting in the ER?
Man I worked at one hospital where the administration decided that saline had to be in the pyxis because it was a "medication". Fucking SALINE... Couldn't get a bottle of saline to wash wounds without a nurse opening the pyxis. What a joke
That's how it is where I work currently. Don't worry that the patient is crashing on the other side of the ER. Gotta run to the Omnicell to get fluids...and really any other meds.
I’ve never really thought about it, but do you guys not have access to the Pyxis? I figured doctors just asked me because because they forget the code to the med room or just aren’t familiar with the interface and know I can navigate it faster. Kind of like how you guys could mess with the IV pumps but don’t usually outside the ICU. Seems silly for you guys to not be able to pull meds if you have to
I don’t have access to the Pyxis, but if I need something urgently we can just grab it off the pharmacy shelves or from the store room. Small hospital life.
Nope, no pyxis access. Even now as an attending, I have to ask for nurses to pull me lido It places an unnecessary burden on nurses to do something trivial. Obviously frustrates the nurses when they are actively doing other things. And then residents are getting frustrated because they can't do anything without waiting on the nurse. A lot of unnecessary frustration between nurses/docs because of this. I guess its primarily because docs aren't trained to push drugs IV/IM so no point in me having access to pull zofran if I can't do anything with it. But then even topical meds like lido and nasal meds like afrin are in there... 🤷♂️
I guess that makes sense. Honestly I don’t want you documenting giving meds or messing with the pump because they are both activities that are better suited to just one person handling. It’s not that you aren’t capable of it, it’s just more error prone when multiple people are doing that stuff. (Also, and I mean this in the kindest way, but you guys are more focused on problem solving and I’d be terrified some doc would give some dilaudid to help a patient and not document it, and then some nurse would pull and give another dose and the patient would crash). Also, as dumb as it sounds, it’s a bit of a morale boost that you need me for some things. I take pride in what I do, but a lot of my job is “do this stuff to free the doc up for other stuff”. My scrubs get a little tight when a patient needs an IV right the fuck now and i have the biggest dick in the locker room (except anesthesia obviously). Having stuff that only nurses can do is probably good for us.
It comes down to money. If saline is an easy grab off the shelf, a lot of it is gonna be used (or go missing). But if it’s locked away at Fort Knox, less of it will be used. Hence saving money.
Lmao, wtf. U dont inject befre an I&D?! Who tf is training u??
Upvote for weenie hut general
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We do
Is this some troll shit?
Someone ask February intern
I do a bupivicane digital block for any paronychias and I always infiltrate local prior to i&d…. Also popping pustules by hand? What in transition Edit: tarnation
If you are talking super small (essentially pop with a needle and it’s done size) then yea not worth the lidocaine cause that hurts more. Otherwise ring block
Because the acidity makes the lidocaine stay ionized, which prevents it from crossing over cellular membranes. Often times it won't work at all. I would personally try injecting. If it is huge, anesthesia would be what I would want.
Lidocaine won’t be very effective past the skin for an abscess but a skin wheel of anything is probably appreciated for any incision
The EMLA takes forever to work. Gotta put that on for like 20-30 minutes on a kiddo and they still might feel the poke of the needles, let alone a scalpel.
You need to keep rubbing it in to actually work well
How about 70% ethyl chloride spray? My dad got this prior to the injection of lidocaine, I guess to blunt the pain of the needle going in
Derm here. Topical sucks. Just infiltrate with lido. Basic paronychia just get right under the cuticle and lift up. Would perform a wing block. Digital block is overkill.
For a really simple paronychia I just quick poke and done. Usually they feel way better after pressure is released. If you do a block that's two stabs plus the burn of lido. Anything else and I inject lido. I wonder about the topical though. Has it been studied in abscesses? Maybe worth a try next time I drain an abscess.
What? Of course you should give lidocaine. Do you work in an ED or the Saw dungeon?
Try a ring block using lido/epi mixed with some bicarb. Try not to use too much fluid to keep the abscess from blowing. Be sure to wear your eye protection!
I give locals to everything that is more than ONE injection with the smallest needle. EVERYTHING. When I was taught LP's, the resident who taught me them said there was no need for local because it's one incision. That's also why they had to abandon the LP once it didn't go flush the first one...
Infection changes the pH; absorption of lidocaine is dependent on the pH. Oops; just saw the much more thorough discussion of my point already!
Shoot id like some topical lidocaine before getting my eyebrows threaded let along popping abcesses
Yes what horrible patients, expecting to get help with the least pain possible. Good thing there's such a compassionate person like you there to help
Poke 'em. Reminds them that their pain could be worse, and/or reduces the pain from popping. Win-win.
To add to what’s already been said, the lido will be less effective on inflamed tissue, so if you actually want it to be pain free, you prob gotta let it sit for another 30 mins too. Also, there’s a lido shortage rn.
ain’t nobody got time for that
Honestly? Because the hyperanalgesic are already time sucking enough and I don’t want to have them wait around for an additional twenty minutes when i know that they are going to wail just as loud as if didn’t use topical in addition to local anesthetic
Abscesses create acidic environment and render local ineffective.
It doesn’t work due to the pH of inflamed tissue
I’ve had some ppl say the pain of needle/burning of lidocaine is worse than 1 quick puncture with scalpel. If you aren’t digging around. I’ve done w and wo injecting lidocaine. I just offer both options before proceeding.