The Procedural Pause
Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.
The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.
The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.
Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.
Wednesday, June 8, 2016
BY MARTHA ROBERTS, ACNP, CEN
This Father's Day, Emergency Medicine News would like to recognize a true leader in emergency medicine. James R. Roberts, MD, a distinguished professor and emergency physician, is one of the founding fathers of the specialty. Since 1972, he directly assisted in building the profession, paving the way for thousands of individuals who now call the ED their home.
Dr. Roberts was one of the first emergency physicians in the country, and he has taught tens of thousands of students over the years including physicians, fellows, residents, nurse practitioners, physician assistants, and nurses. His expertise is recognized worldwide, and his procedure textbook, Clinical Procedures in Emergency Medicine, is a staple in every ED, not to mention the global reach of his EMN column. (http://emn.online/INFOCUS-JR.) Dr. Roberts' clinical work in the ED and his toxicology expertise have helped saved the lives of thousands of sick children and adults.
This video is a small collection of images highlighting some of his work in emergency medicine. Many of these photos were captured during my first clinical rotation alongside Dr. Roberts and his team at Mercy Hospital of Philadelphia, where he was chairman for more than 20 years. It would be impossible to compile a video of all the photos he took of patients and procedures over the past decades, but these are some of the most memorable.
Not only has Dr. Roberts groomed students and new practitioners, he has also taught many, including me, the art of the profession. It's not often you find his kind of intelligence anywhere, but when you do, it is rarely in his modest form. He manages to effortlessly balance his great intellect with a great sense of humor and wit that makes practicing emergency medicine rewarding, interesting, and fun.
I am truly lucky to call him Dad. He taught me everything from my ABCs in grade school to the ABCs of ED patients. He is a truly unique and dedicated soul, but he is, above all else, a caring person. Not only is he highly educated, he practices with feeling, intuition, common sense, and passion. His modest mentorship and enthusiasm for emergency medicine is contagious, in a good way.
This fall during the American College of Emergency Physicians Scientific Assembly in Las Vegas, Dr. Roberts will receive the award for Outstanding Contribution in Education. In nominating him for that award, Anthony S. Mazzeo, MD, wrote, "He has educated physicians worldwide on the nuances of all aspects of EM, from the mundane to the exotic, all with the charisma and erudite vocabulary that is undeniably 'trademark Roberts'. … Dr. Roberts remains a humble, modest, dedicated, and hard-working educator who would clearly never seek the recognition of this award. However, those of us who have worked with Jim and learned from Jim over the years feel this recognition is undeniably warranted."
Happy Father's Day to all the fathers of emergency medicine, and Happy Father's Day to my Dad, James R. Roberts, MD.
Thursday, June 2, 2016
It's time to be fearless and embrace the true utility — and maybe implement a new policy in your ED — of ultrasound-guided intravenous (IV) line insertion.
Many physicians, NPs, and PAs already know how to place US-guided IVs, but we can help teach those who don't. Provider teaching can be in the form of real-time IV placement or a short 60-minute procedural training course open to all those who are interested. You can even use our procedural videos to help get you started! (http://emn.online/Mar16PP.)
We all know our difficult patient population includes prior IV drug abusers, obese patients, patients with chronic illnesses, and hypovolemia. Let's make the procedure less painful for them! No one is asking for our nurses to place central lines or diagnose a DVT using US, but basic understanding of US technology is not difficult and can be beneficial for the patient. A delay in establishing vascular access can result in a delay in the administration of a fluids and medications.
Patients frequently experience delays in diagnosis and initiation of treatment. Multiple attempts at attaining vascular access also result in frustration and a loss of productivity by the treating team. (Clin Pediatr [Phila] 2009;48:895.) (Rauch, Dowd, Eldridge, Mace, & Schears, 2009). Nurses and technicians are more likely to establish a well-placed, working IV site once they can identify the veins and arteries on the screen. This could help speed up treatment for a patient who needs an 18 g needle for a CT scan to rule out a PE or a septic patient who needs resuscitation.
n Ultrasound-guided intravenous line placement
n Using sterile approach
Make sure this particular procedure is already approved for immediate use. The emergency medicine technicians (EMTs) can use the US machine to insert IV lines in most hospitals, but in other institutions, RNs are allowed to do this without an order. And still, some facilities allow only a physician or midlevel to run the procedure.
n Inform patient of need for intravenous line.
n Alert nurse and EMT team or place order for IV line.
n Nursing or EMT team attempt standard IV insertion. A US-guided approach should be activated if IV placement cannot be obtained within two attempts. NOTE: Consider creating a standing order or policy for department to allow nurses to complete this activity on their own without waiting.
n Regardless of who is initiating line placement, obtain the following items: appropriate-sized catheter (18 g is suggested), chlorhexidine prep pad, tourniquet, IV line set up or start kit with NS flush, sterile towel, and marking pen. Also obtain the US machine with linear probe, sterile US gel packets, US probe sterile plastic cover, sterile gloves, and any other equipment (i.e., culture bottles or lab testing tubes).
n Obtain written or verbal consent for the procedure.
n Prepare for US-guided IV placement. First, use the linear probe to examine the arm without a tourniquet. Attempt to locate deep and superficial veins for IV cannulation. Consider deep brachial veins and move the probe slightly higher up the bicep to look for deeper veins.
n NOTE: Remember that arteries will be pulsating and veins will not. If you turn on the color indicator, arteries will also appear red and veins will appear blue.
n Continue to look for veins by pressing down on the probe. Veins should be easily compressible. Add the tourniquet. Continue your search.
n Once you have located the vein you wish to cannulate, use the marking pen to mark the site. Note the depth on the US machine so you know how far to advance your needle.
n This is where it gets a little tricky. If you are confident that you can stick the vein without continuous US guidance, you can clean and prep the site and then insert the needle. At this point, you will be finished with the procedure.
If you are unsure, then you need to take this a few steps farther:
n Clean the site with chlorhexidine.
n Add sterile gel to the site on the arm you plan to cannulate.
n Set up a sterile towel on side table, and drop your sterile needle onto it. You will use the towel later to wipe off any extra gel. It's good to be prepared.
n Don sterile gloves.
n Ask an assistant to open the US probe-cover packet. Grab it and ask the assistant to squeeze gel inside the sleeve of the US probe cover. Do not break sterility.
n Have your assistant place the linear probe into the sleeve as you expand it over the full length of the probe and cord. Do not break sterility.
n Place the sterile-covered probe onto the site you already examined.
n Relocate the vein using your landmarks and markings.
n Use the US-guided technique to watch your needle enter the skin and cannulate the appropriate vein.
n Complete IV setup once the vein has been properly cannulated and the outline setup has been connected.
n Clean off the arm with the towel to remove any extra gel or blood.
n Complete the procedure by securing the IV line, drawing labs or cultures (if indicated), and flush the line with NS. NOTE: We often suggest that providers draw a 10 mL syringe of blood during initial placement, which can be placed in your sterile field prior to starting the procedure.
n If your patient is a frequent flyer and you know a line will be tough, try to use the US technique immediately, before completing two blind sticks.
n Do not forget to remove the tourniquet when the procedure is complete.
n Do not break your sterile field. You are cannulating a deep vein, and the potential for artery cannulation is possible.
n Immediately remove the IV catheter, and add pressure to any site where arterial cannulation was inappropriately completed.
n Consider US of the upper extremity to rule out DVT if a patient returns to the ED with arm pain after a deep vein cannulation and signs of DVT.
Tip of the Week
Feel free to ask your administration if you can create a policy for US-guided IV placement and explain why it is beneficial for patient care (pain control, expedited testing etc.) and nursing autonomy. Consider offering to teach a 60-minute lab on US-guided IV insertion.
Using ultrasound for IV access requires training, and the literature is mixed. Physician training is incorporated into residency training with up to 16 hours of didactic and more than 100 ultrasound scans. It is suggested that "nursing and technician staff members train with at least one hour didactic with additional hands on training." (J Emerg Med 2006;31:407.)
The Emergency Nurses Association's policy supports US-guided IV placement by physicians, nurses, and techs in the appropriate setting. Read more about it at http://bit.ly/1iy4taJ.
Click here to watch a video of ultrasound-guided intravenous line insertion, and read the first three parts of this series:
Part 1: We Had You at Ultrasound
Part 2: Foreign Body Removal
Part 3: Eye Think It's the Retina
Watch this month's video.
Monday, May 2, 2016
Part 3 in a Series
The Problem: Unilateral, painless vision changes and floaters
Ocular ultrasound is a short and sweet procedure that could change your practice and greatly benefit your patients. It can actually be used to diagnose retinal detachment, which in the past required a referral to an ophthalmologist and often led to delayed therapy. Noninvasive and simple ultrasound techniques can be used on any patient of any age presenting with visual changes. The differential for visual changes with or without complete vision loss or blurry vision encompasses a daunting list. This is for you especially if retinal detachment is on your differential.
First, let's review the anatomy. Visual messages are sent from the retina through the optic nerve to the brain. Patients experience painless, unilateral vision loss, which may be permanent if for some reason the retina becomes detached, moves, or is pulled away from its normal position. Other problems, such as retinal tears or breaks, can cause brief vision loss and can lead to future complete detachment. ("Facts about Retinal Detachment," NIH, National Eye Institute; http://1.usa.gov/21P46bg.) Patients will complain of unilateral vision changes without other symptoms aside from blurry or cobweb vision or floaters (photopsia). Some say they even see black, which can be the last fatal phase of retinal detachment.
Ocular structures. Photo courtesy of CreativeCommons.com
Things you can see with ocular ultrasound:
- Retinal detachment
- Posterior vitreous detachment (PVD)
- Vitreous hemorrhage
- Lens dislocation
- Choroid detachment
- Intraocular foreign body
- Globe rupture
- Orbital fractures
- Central retinal artery and central retinal vein occlusions
The Possibilities: History taking
Ask your patient the following questions before performing your ultrasound-guided exam:
- Are you nearsighted?
- Have you had painless vision loss?
- Have you had a prior retinal detachment?
- Is there a family history of retinal detachment?
- Have you had cataract surgery? Recent eye trauma?
- Did it seem like a dark curtain came over your eye?
- Do you have a history of uveitis, degenerative myopia, or other eye complications?
- And most importantly, have you experienced an increase in the number of floaters, cobweb-like vision, or cloudy/flashy vision in one eye in the past few weeks or months?
If your patient said yes to any of these questions, it's time to break out the ultrasound machine and be prepared to look directly at the retina. Remember, a retinal detachment may occur at any age, although it is more common in those over 40 and Caucasian males. (http://1.usa.gov/21P46bg.)
The Procedure: Ocular ultrasound
- Ultrasound-guided identification of retinal detachment using the linear probe
- Identification of structures: Anterior (lens, cornea, iris, ciliary bodies) and posterior chambers (vitreous, retina, optic nerve sheath diameter [ONSD], optic disc)
- Identification of normal retina vs. detachment
- Prompt and appropriate follow-up with retinal specialist if defect found
- Measurement of ONSD if concerned about elevated intracranial pressure
- Complete an excellent history and fundoscopic exam.
- Obtain an ultrasound machine.
- Put your patient in a supine position.
- Engage linear probe (7.5 MHz or greater). Set the machine in B-mode and activate the "ocular" preset.
- Place a clear Tegaderm over the patient's affected eye after he closes it. This will prevent the lubricating gel from getting into his eye. It also does not pull off eyebrows or eyelashes. Tell the patient this prior to application, and that it prevents any foreign bodies from entering the eye or causing eye irritation.
- Smooth out any air bubbles in the Tegaderm.
- Add lubricating gel over the Tegaderm.
- Darken the lights in the room.
- Be prepared to use the probe in the transverse plane. The indicator should be pointing toward the patient's ear (i.e., you are looking at the left eye, the probe is held in the transverse or horizontal position with the indicator pointing toward the left ear).
- Gently place the linear probe over the Tegaderm and adjust your depth to see the entire globe: the anterior and posterior chambers and ONSD. Identify all structures.
- Locate the retina and determine if detachment has occurred. You will see a white line flopping around and waving gingerly at you on the screen. It looks almost like a streamer.
- Pull off the Tegraderm to reveal a dry, non-irritated eye and complete appropriate follow-up. Immediately call for assistance if there is a detachment, and refer to ophthalmology.
- Note: If you wish to measure the ONSD, it should be <5 mm. The provider should be concerned about elevated intraocular pressure if it is >5 mm. Studies have shown these two ailments have a direct clinical correlation. Start in the transverse plane when you measure. Measure the width of the optic nerve sheath 3 mm posterior to the retina and then "rotate the transducer clockwise to measure the ONSD in the sagittal plane, perpendicular to your first measurement. (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)
- Compare both eyes.
- Limit your examination of the eye(s) with the ultrasound and adhere to ALARA principle (as low as reasonably achievable).
Click here to watch a video of ocular ultrasound.
Special thanks to Amie Woods, MD, an emergency physician at INOVA Fairfax Hospital and an assistant clinical professor at George Washington University, for her help in making this video.
This procedure may initially sound difficult and above your level of expertise, but once you see a retinal detachment on ultrasound, you will never forget it. Discovering a retinal detachment is as simple as turning on the machine, using your linear probe on the affected eye, and examining the globe and its structures.
The retina itself is usually a flat white thickened line, which lies securely among the tissues at the back of the eye. A normal globe itself will appear dark (the vitreous), and the retina will appear white.
A significant detachment will show the white retinal tissue flopping and waving around in the black area, close to its normal resting place. Sometimes, you may be able to identify PVDs or hemorrhages. PVDs are usually thinner and smoother than retinal detachments and are more mobile. Retinal detachments should also not extend to the ciliary bodies because of their anatomy while PVDs usually do. A retinal detachment should also not extend over the optic sheath. Retinal detachments will be thicker, white (hyperechoic) membrane-like structures with multiple folds and move with ocular movements. (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)
Retinal detachment as seen on ultrasound ocular exam. Photo courtesy of Dr. Amie Woods, Inova Fairfax Hospital
Keep in mind, your patient may still have a retinal artery occlusion (RAO) or spasms even if the retina appears normal. These patients may present with similar complaints of vision loss or changes caused by clots or blocked retinal arteries. The retina is starved of oxygen and nutrients and essentially dies and causes these symptoms. RAO may occur in patients who are symptomatic and without retinal detachment or who have a history of atherosclerosis. Final exam tip: You may see macular edema on your fundoscopic exam if you suspect RAO. RAOs can be treated with lasers, blood thinners, and treatments used for atherosclerosis.
Our retinal partners use a freezing treatment called cryopexy to fix the retina with lasers. They basically fuse it back in place. The majority of retinal detachments are treated successfully if identified quickly by the emergency department provider. Remember, the retina is at high risk for complications and requires an ophthalmologist's care.
- Don't push too hard on the probe. You won't need to apply much pressure at all if you use enough gel.
- Use the bridge of the patient's nose or his forehead to stabilize your hand.
- Use a dark room.
- Keep it clean. Use the Tegaderm approach.
- Obtain a fundoscopic exam prior to the ultrasound exam.
- Test the visual acuity.
- Use the "freeze" button on the machine to hold your image on the screen so you can complete the identification and measurements of the globe's structures. This allows you to look longer and closer without leaving the probe directly on the patient's eye. It also allows you to measure the ONSD accurately.
- If you suspect ruptured globe and see that while doing your exam, stop and call the specialist immediately. Refrain from using tense pressure on the orbit.
o Warm lube? No way, this is not a fetus! Chilling the lube actually allows you to complete a better exam because it causes increased viscosity and "allows the gel to stack easily." (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)
- Retinal detachment and PVD are difficult to distinguish, but patients may be more likely to say they see floaters as opposed to having vision loss if suffering from PVD.
Procedural Pause Overachievers
If you really want to impress your ophthalmology colleagues, you can also measure the blood flow to the retinal artery based on a very simple equation related to the diameter measurements and blood flow seen on the ultrasound exam. If you want to know more about this, check out this great Austrian study by Droner, et al. (Curr Eye Res 2002;25:341; http://bit.ly/25snrDM.)
BONUS VIDEO: Watch Dr. Amie Woods' TEDx talk, "This is What's Making Me a Better Doctor," for her experience with ultrasound and a patient with a life-threatening condition: http://bit.ly/1VucDAx.
Friday, April 1, 2016
Part 2 in a Series
Are you ready for summer? That means more bare feet, flip-flops, and the potential for foreign bodies of the foot and toe. We will continue to highlight tools and tricks to help you master soft tissue foreign body removal in the emergency department. A refresher on the basics of ultrasound is available in our blog post from last month: http://emn.online/1UGtduz.
Foreign bodies of the toe or foot are common presentations in emergency departments, and one way to determine the size and shape of retained superficial foreign bodies is to use ultrasound and the linear probe. This simple technique may help you locate certain items quickly and more efficiently than just radiographs alone. We do, however, suggest obtaining plain A/P and lateral films of the foot or toe prior to completing this procedure.
Keep in mind, only radiopaque foreign bodies (metal, glass, pencil graphite, gravel, and stone) will show up on plain film radiographs. All glass is radiopaque, and only small size limits its radiographic detection. Other objects, especially wood, plastic, dirt, cloth, aluminum, toothpicks, and small bones, are radiolucent and usually cannot be seen on plain films. Hidden retained wooden items guarantee a subsequent infection, which may cause extensive problems such as repeat visits, abscess formation, and surgeries, but studies show ultrasound is a useful tool to detect their presence. (J Emerg Med 2002;22:75.)
One study agreed, finding that ultrasound detected 21 of 22 foreign bodies with a sensitivity, specificity, positive predictive value, and negative predictive value of 95.4 percent, 89.2 percent, 87.5 percent, and 96.2 percent, respectively. (Clin Radiol 1990;41:109.)
Foreign bodies are often missed on the initial exam even if a plain film radiograph is obtained. A retrospective review looked at 200 consecutive patients with foreign bodies in the hand, 95 percent of whom had wood, glass, or metal in their hand. Their follow-up lasted for approximately six weeks. Some of the injuries were treated immediately while others were removed up to 20 years later in the office or in the emergency department. Interestingly enough, providers initially treating patients missed 30 percent of the foreign bodies even when a plain film radiograph was obtained. Metal was visible in all of the radiographic studies obtained, glass in 96 percent, and wood in only 15 percent. (Am J Surg 1982;144:63.) Because ultrasound can assist with finding radiolucent objects, this simple intervention may help you successfully remove these objects on initial presentation before they can cause additional problems.
The Plan and Approach
< Obtain a radiograph of problem area.
< Use bedside ultrasound to locate abscess and foreign material.
< Anesthetize the problem area.
< Open, drain, and explore abscess.
< Wash it out.
< Remove any additional foreign bodies with tweezers or hemostat probing.
< Pack the wound if indicated. Do not suture closed!
< Apply a dry, bulky dressing.
< Follow-up with podiatrist in 48 hours.
Anytime you plan to remove superficial foreign bodies in the skin, be sure to clean the area well and irrigate the problem area. This will ensure proper cleaning and debridement.
< Obtain plain A/P and lateral films of the affected area.
< Place the patient in a supine position.
< Elevate the foot onto tightly rolled towels as needed for positioning. Place several under the ankle and some under the patient's knee. Note: Pillows are not helpful because the foot rolls to the middle and is not properly elevated.
< Set up the ultrasound machine. Use the linear probe at a depth of approximately 2-4 cm (depending on superficiality of the object) and adjust the gain as needed.
< Locate the pocket of pus or fluid as well as any retained foreign bodies.
< Clean the entire affected area and associated areas with Betadine or chlorhexidine.
< Use a 22 or 25 g needle to inject 1-2 mLs of 1-2% lidocaine (usually with epinephrine/bicarbonate) to the affected area. Be sure to stabilize the foot or toe to avoid sticking yourself.
< An option is to use a blood pressure cuff on the calf to obtain a bloodless field.
< Use a tourniquet if you are working on a toe. Do not forget to cut it off when your procedure is completed.
< Clean the area with additional prep to ensure a clean site.
< Depending on the site of penetration, make a linear (or horizontal) incision using an 11 blade scalpel. Make sure the incision is large enough to allow probing and drainage of the abscess.
< Probe the area for the foreign body, feel for and look for the foreign body, and remove and deloculate the abscess.
< Use the ultrasound guidance (sterile covering) to continue examining the area for any retained foreign bodies.
< Wash out the wound with simple irrigation. This may require several attempts.
< Avoid jet irrigation because this may push foreign bodies farther into the skin.
< Tap water irrigation is fine, even in children. (Ann Emerg Med 2003;41:609.)
< Insert packing as needed. Packing may be indicated if the wound is bleeding. Note: Best to avoid suture closing.
< Packing is usually not required, and the wound can be re-examined in two days.
< Place a dry, bulky dressing over the wound and assist the patient with crutch training. Have the patient elevate the foot several times a day.
< Did you make sure the tourniquet was cut off?
< Tell the patient to follow up with the podiatrist or the ED in 24-48 hours for wound re-evaluation.
< Consider adding antibiotic coverage for Pseudomonas for more complicated wounds, infected cellulitic-appearing abscesses, diabetic, HIV+, or immunocompromised patients.
Be careful not to cause further damage to this already irritated area. The thin skin around the toe and foot can be easily destroyed with excessive irrigation, probing, and incisions. This may cause increased scarring, pain, deformities, and distress to the patient.
Watch the video here.
Remind the patient that elevation will help with pain, swelling, and overall healing. Crutch use will assist with decreased bleeding and pain. Motrin or Tylenol are acceptable treatments for post-procedure pain, but some patients may benefit from a short course of stronger pain control such as Norco or Percocet. Use at your discretion.
Not all abscesses need packing. It is suggested that bleeding wounds do, and simple, smaller abscesses do not. Often, it is not what you put in it, but what you take out of it. The literature is still mixed on final recommendations for wound packing. It was used in this particular case and removed in less than 48 hours. It helped control the bleeding and keep the wound open for drainage.
Notes on packing and pain: Patients who have packing placed often have more pain and need medications like ibuprofen and other narcotics. (Acad Emerg Med 2009;16:470.) It is uncertain if the risk benefit of packing is needed for these patients, and it may even delay healing, increase complications, and create a need for secondary interventions.
One study found packed wounds may result in delayed wound closure, with closure times basically doubled. They found the rate of wound reoccurrence, however, was equal. (Am J Emerg Med 2011;29:361.) Update the patient's tetanus shot if it has not been done in the past 10 years. (Am Fam Physician 2007;76:683.)
Do I give antibiotics? Not usually. The treatment for these injuries is to remove the foreign body and drain any abscess associated with the item. Give some thought to the patient's presentation and current state, especially because these are considered penetration injuries. Continued infected or irritated sites require you to look for more foreign bodies. Risk of infection increases with prolonged foreign body retention, dirty wounds, and medical history of diabetes, HIV, etc. The use of prophylactic antibiotics is not typically recommended in non-bite wounds (even with foreign body presentation) or simple wounds. (Am J Emerg Med 1995;13:396.) No hard and fast rules apply for treatment unless you suspect Pseudomonas as a potential culprit. Dog or cat bites with retained teeth should be placed on Augmentin.
Antiseptic agents such as hydrogen peroxide and povidone iodine should not be used, especially on the packing in the wound. These can be toxic to tissue and may slow healing times. The debate is still out about chlorhexidine. (Am J Dis Child 1987;141:27.)
It is best to tell the patient and document on the record that more foreign material may be in the area even though you removed a foreign body, and there are no guarantees that you got all of it. If prolonged pain or infection occurs, additional foreign bodies may be present. When all else fails and a foreign body is still considered, a CT scan should be ordered.
Tip of the Week from Lawrence Stern, MD, in Fairfax, VA:
Packing most wounds (post-abscess drainage) is simply not necessary based on my experience and studies. One of the best times to pack a wound is if it is a very large incision or if the abscess cavity is bleeding. The majority of the time, packing is not required, even with larger abscesses. Packing will, however, keep the wound open and control the bleeding when indicated.