Zone 2 neck abscess

[saintsfan180]

Hey guys, just wanted a few opinions on this. I saw a patient a couple of weeks ago with a large abscess on zone 2 of the neck. I told my staff that I obviously didn't feel comfortable draining this and he seemed confused. He acted like it was perfectly fine and that there was no way I'd hit anything. I basically refused and we ended up having surgery do it. I have spoken to a few other ER residents aand the general consensus is that they wouldn't go near this dude with a scalpel either. Was I wrong? Who would feel comfortable doing this in the ED?

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[name?]

If it's clearly a superficial abscess, I'd ultrasound for landmarks and do it. In fact, did it last week on a shooter with a big goober on his neck.

 

[Doctor Bob]

Hey guys, just wanted a few opinions on this. I saw a patient a couple of weeks ago with a large abscess on zone 2 of the neck. I told my staff that I obviously didn't feel comfortable draining this and he seemed confused. He acted like it was perfectly fine and that there was no way I'd hit anything. I basically refused and we ended up having surgery do it. I have spoken to a few other ER residents aand the general consensus is that they wouldn't go near this dude with a scalpel either. Was I wrong? Who would feel comfortable doing this in the ED?

Assuming it's a superficial abscess (the kind we drain in the ED all the time)...

I'd be comfortable with draining this. Your approach shouldn't take you anywhere near the dangerous structures in the neck.

But this raises a few questions for me.
1) Hypothetically if you saw this patient in a community hospital, and you didn't have surgery available to come see the person, how would you have managed them?

2) As a resident there will be times when you feel uncomfortable with a procedure. But if your attending wanted you to do the procedure, when you balked, why didn't they do it themselves? How did surgery end up getting involved (assuming your attending's hands were not broken).

3) Whoever ends up doing the procedure, did you go help with it so you would feel more comfortable next time? If surgery takes the patient to the OR that's one thing (you shouldn't be doing those kinds of things in the ED). But if they come and open it up in the department (especially if it's a surgery resident doing it), there's no reason why next time you can't do it.

 

[Janders]

With bedside U/S, I may feel OK with regards to the carotid/jugular. It really depends on exact location/size of said abscess.

Don't forget CNXI which has a rather superficial course...

 

[pinipig523]

I would not touch it unless it was far >5cm from the vascular structures via US.

 

[dotcb]

I would ultrasound and determine if I felt comfortable incising it.

 

[suckstobeme]

Did the surgeons do anything different? If it was a plain old superficial abscess, I don't think I'd have a problem with it. I guess it's hard to say without knowing size/location. I mean was there something specifically about size or location that worried you? Did you think it was right on top of the carotid or something?