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was large, or the capsule cannot be entirely removed, manage the mass as an inflamed subcutaneous mass
(see below). Otherwise, send the specimen to the pathologist for evaluation. Control hemostasis by gentle
pressure. Irrigate the wound, then close it in one or two layers. Close the dermal layer using inverted,
interrupted stitches with dissolvable suture. Include some fat in the stitch if the dissection extended into the
fat tissue. Follow the standard guidance above. Use this surgical approach for the removal of all non-infected,
subcutaneous masses such as lipomas or fibromas. It is important to send lesions for pathologic evaluation,
as further radical surgery may be necessary for the rare malignancy.
Inflamed superficial or subcutaneous mass:
Treat with appropriate antibiotics. If the lesion is an EIC that responded to therapy, treat as in the previous
paragraph. If the lesion is an abscess or unresponsive EIC (or similar lesion, such as furuncle), interferes with
the mission performance and cannot be safely managed until the end of the mission, perform the following
surgery. Mark any sinus tract by placing a needle or other object into the tract. Incise the abscess/cyst
(avoid spraying the contents on any person) and evacuate its contents. Explore the cavity with a hemostat
and spread the jaws to break down walls and adhesions in the abscess. If the abscess had a sinus tract
communicating with the epidermis, open the tract and expose it to therapy. Obtain hemostasis with pressure.
Irrigate with hydrogen peroxide or saline and pack with damp (sterile saline) 2x2s or 4x4s (or iodoform), and
apply a dry dressing. Do not close this infected wound. Do not continue antibiotics unless cellulitis is severe,
the infection does not resolve with I&D or the patient is immunosuppressed (i.e., diabetic, HIV, malnourished,
on chemotherapy). Then continue antibiotics only until the wound demonstrates that it is healing. Start
wet-to-dry dressings.
Wet-to-dry dressings: This requires moist packing that “dries” during the interim between dressing changes.
When the packing is removed, it debrides the wound by removing the dead cells that stick to it. Do not allow
the packing to dry completely. If it does, then change the dressing more frequently. Remove the packing
daily with non-sterile gloves, irrigate the wound, and replace the packing until the wound closes (1-3 weeks).
The irrigation does not need to be “sterile” as potable water can be used (the wound is already colonized
with skin flora and is by definition not sterile). NOTE: Only the wound should be in contact with the moist
dressing, because exposure of the surrounding skin to the continuous moisture can denude the skin and lead
to further infection. The patient can even remove the packing, take a shower and wash the wound with a
soap and water, before repacking the wound.
What Not To Do:
DO NOT leave obvious cyst wall behind in the wound.
DO NOT close grossly infected wounds.
DO NOT forget to send the lesion to a pathologist.
DO NOT attempt to remove a lump over a joint at the wrist or fingers- this is often a ganglion cyst and
connects directly to a tendon sheath and the joint space.
Procedure: Joint Aspiration
COL Warren Whitlock, MC, USAWhen: To analyze joint uid for suspected infection or for therapeutic reasons; relieve pain by draining an
effusion from a swollen synovial space; instill medications/steroids.
What You Need: Alcohol swabs, Povidone-iodine prep solution, sterile gloves and towels, gauze, forceps,
local anesthesia with ethyl chloride vinyl spray and/or lidocaine 1%, appropriate syringes, needles, and
chocolate (Thayer-Martin) media if gonococcal arthritis is suspected.
What To Do:
General Procedure
- Identify landmarks and mark the entry point with a scratch or indentation on the skin.
- Sterilize the skin in a wide field around the puncture site.
- Anesthetize the skin with the 1% lidocaine with the 10-ml syringe and 22 to 27-gauge needle; continue