Management of Axillary Abscess in the Emergency Room
Axillary abscesses without systemic symptoms should be drained in the Emergency Room rather than referred, as surgical drainage is the definitive treatment for abscesses regardless of location.
Assessment of Axillary Abscess
Evaluate for:
- Fluctuance, erythema, and warmth in the axillary region
- Size and depth of the abscess
- Extension of cellulitis into surrounding tissues
- Systemic symptoms (fever, chills, hypotension) which would indicate more aggressive management
Risk factors to consider:
- Diabetes mellitus
- Immunocompromised status
- History of MRSA infections
- Recent weight lifting or gym use 1
Management Algorithm
1. Drainage Procedure in ER
- Incision and drainage is the primary treatment for axillary abscesses 2
- Local anesthesia is typically sufficient for smaller abscesses
- Consider ultrasound-guided axillary nerve block for larger or more painful abscesses 3
- Ensure complete drainage of the abscess cavity to prevent recurrence
- Obtain cultures of the drained material to guide antibiotic therapy
2. Antibiotic Therapy
For uncomplicated abscesses without systemic symptoms or extensive cellulitis:
- Drainage alone may be sufficient
- Consider empiric antibiotics with MRSA coverage if risk factors present
For abscesses with surrounding cellulitis:
3. Follow-up Care
- Wound packing (though no strong recommendation exists regarding packing) 2
- Daily wound care with cleaning and dressing changes
- Follow-up evaluation in 48-72 hours to assess response to treatment
- Complete the full course of antibiotics if prescribed
Special Considerations
When to Refer
- Refer to specialist if:
- Abscess is exceptionally large or deep
- Multiple loculations are present
- Patient has significant comorbidities affecting healing
- Suspicion of underlying malignancy 5
- Failure to respond to initial treatment
- Recurrent abscesses in same location
Pitfalls to Avoid
- Delaying drainage: Surgical drainage should not be delayed once an abscess is identified 2
- Incomplete drainage: Ensure all loculations are broken down
- Failure to obtain cultures: Always culture the abscess material, especially in high-risk patients 2
- Missing underlying conditions: Non-healing axillary abscesses may indicate underlying pathology such as malignancy 5
- Inadequate follow-up: Ensure proper wound care instructions and follow-up plans
Warning Signs Requiring Urgent Reassessment
- Development of systemic symptoms (fever, hypotension)
- Spreading cellulitis despite treatment
- Increased pain or swelling
- Purulent drainage that does not decrease with time
- Signs of Staphylococcal Toxic Shock Syndrome 6
By following this approach, most axillary abscesses without systemic symptoms can be effectively managed in the Emergency Room setting without the need for specialist referral.