Along with the causes of dark, Split nails are often caused by an injury such as a stubbed toe or receiving a severe blow to a finger or thumb. Abscess Incision and Drainage | NEJM The abscess drainage procedure itself is fairly simple: If it isnt possible to use local anesthetic or the drainage will be difficult, you may need to be placed under sedation, or even general anesthesia, and treated in an operating room. Evaluating the extent and severity of the infection will help determine the proper treatment course. Treatment of Skin Abscesses: A Review of Wound Packing and - PubMed Cover the wound with a clean dry dressing. You can learn more about how we ensure our content is accurate and current by reading our. Pediatr Infect Dis J. Check your wound every day for any signs that the infection is getting worse. Preauricular abscess drainage without Incision: No Incision-Dr D K Gupta. The standard treatment for an abscess is an abscess I&D. During this procedure, your general surgeon will numb the surface of your skin, and an incision will be made to drain pus and debris from the boil. 15,22,23 The addition of systemic antibiotic therapy is recommended if the patient has signs and symptoms of illness, rapid progression, failure to respond to incision and drainage alone, associated comorbidities or immunosuppression, abscess in . Your healthcare provider can drain a perineal abscess. 33O(d9r"nf8bh =-*k6M&4B 3J=yD)S'|}Zy#O 5\TCwE#!,k4Uy>vkcb/NB/] %H837 q'_/e2rM4^zU7z5V^(5*|mfR7`fz6B However, tissue adhesives are equally effective for low-tension wounds with linear edges that can be evenly approximated. The most common mistake made when incising an abscess is not to make the incision big enough. Tips and Tricks When doing a field block, after the first injection always reinsert the needle through anesthetized skin to minimize the number of painful pricks. A deeper or larger abscess may require a gauze wick to be placed inside to help keep the abscess open. We avoid using tertiary references. Also get the facts on causes and risk, Boils are painful skin bumps that are caused by bacteria. At first glance, coding incision and drainage procedures looks pretty straightforward (there are just a . It can be caused by conditions that range from mild, Learn all about dark circles under your eyes. The RCTs failed to show decreases in treatment failure rates with antibiotics, but two studies demonstrated a short-term decrease in new lesion formation. 2005-2023 Healthline Media a Red Ventures Company. A cruciate incision is made through the skin allowing the free drainage of pus. You have increased redness, swelling, or pain in your wound. Care Instructions| A skin abscess is a bacterial infection that forms a pocket of pus. Read on to learn more about this procedure, the recovery time, and the likelihood of recurrence. Your doctor makes an incision through the numbed skin over the abscess. Learn how to get rid of a boil at home or with the help of a doctor. The incision and drainage can be performed with local anesthesia. Routine cultures and antibiotics are usually unnecessary if an abscess is properly drained. An incision is made on the breast over the abscess and a sterile instrument is inserted to break open small pockets of pus. We do not discriminate against, If a local anesthetic is enough, you may be able to drive yourself home after the procedure. If you have a severe bacterial infection, you may need to be admitted to a hospital for additional treatment and observation. Duong M, Markwell S, Peter J, Barenkamp S. Ann Emerg Med. Simply use a dressing gauze that can be purchased from any pharmacy . All rights reserved. Perianal Abscess. 4 0 obj An abscess is sometimes called a boil. Nonsuperficial mild to moderate wound infections can be treated with oral antibiotics. PMC You can pull the dirty gauze out, and gently tuck a fresh strip of ribbon gauze (use one-quarter inch width ribbon gauze for most abscesses, which you can buy at a drugstore) inside the wound. For example, diabetes increases the risk of infection-associated complications fivefold.14 Comorbidities and mechanisms of injury can determine the bacteriology of SSTIs (Table 3).5,15 For instance, Pseudomonas aeruginosa infections are associated with intravenous drug use and hot tub use, and patients with neutropenia more often develop infections caused by gram-negative bacteria, anaerobes, and fungi. There is no evidence that antiseptic irrigation is superior to sterile. Abscess Incision and Drainage (Discharge Care) - Drugs.com & Accessibility Requirements and Patients' Bill of Rights. (2012). After an aspiration or incision and drainage procedure, a few additional steps are taken. sharing sensitive information, make sure youre on a federal A boil is a kind of skin abscess. Healing could take a week or two, depending on the size of the abscess. These infections may present with features of systemic inflammatory response syndrome or sepsis, and, occasionally, ischemic necrosis. Before this procedure, patients might need to begin with antibiotic therapy to treat and prevent any other infections. Fournier gangrene (necrotizing fasciitis) is a surgical emergency and requires prompt hemodynamic resuscitation, broad spectrum antibiotics, and . Penetrating wounds from bites or other materials may introduce other types of bacteria. A systematic review of 11 studies comparing tissue adhesive with standard wound closure for acute lacerations found that tissue adhesives are less painful and require less procedure time.17 The review found no difference in cosmetic outcomes; however, there was a small but statistically significant increased rate of dehiscence and erythema with tissue adhesives. HHS Vulnerability Disclosure, Help Incision and Drainage (Abscess) Wound Care Instructions Incision and drainage after care? | Pilonidal Support Forums Change thedressing if it becomes soaked with blood or pus. Patients may require repeated surgery until debridement and drainage are complete and healing has commenced. 1 0 obj Abscess - incision & drainage - Sunnybrook Hospital Plain radiography, ultrasonography, computed tomography, or magnetic resonance imaging may show soft tissue edema or fascial thickening, fluid collections, or soft tissue air. 18910 South Dixie Hwy., Cutler Bay 305-585-9230 Schedule an Appointment. Superficial mild wound infections can be treated with topical agents, whereas deeper mild and moderate infections should be treated with oral antibiotics. Older age, cardiopulmonary or hepatorenal disease, diabetes mellitus, debility, immunosenescence or immunocompromise, obesity, peripheral arteriovenous or lymphatic insufficiency, and trauma are among the risk factors for SSTIs (Table 2).911 Outbreaks are more common among military personnel during overseas deployment and athletes participating in close-contact sports.12,13 Community-acquired MRSA causes infection in a wide variety of hosts, from healthy children and young adults to persons with comorbidities, health care professionals, and persons living in close quarters. Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. CJEM. Tetanus toxoid should be administered as soon as possible to patients who have not received a booster in the past 10 years. Sometimes a culture is performed to determine the type of bacteria and which antibiotics will work best. However, you should check with your doctor or a nurse about home care. Occlusion of the wound is key to preventing contamination. Incision and drainage of cutaneous abscess with or without cavity packing: a systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials. The above information is an educational aid only. Bartholin's Gland Abscess Drainage - DoveMed Also searched were the Cochrane database, Essential Evidence Plus, and the National Guideline Clearinghouse. Incision and Drainage - StatPearls - NCBI Bookshelf Your doctor may send a sample of the pus to a lab for a culture to determine the cause of the bacterial infection. Plan in place to meet needs after discharge. 04. Incision & Drainage | Hospital Handbook You may have gauze in the cut so that the abscess will stay open and keep draining. However, home remedies could help, like apple cider vinegar and tea tree oil. Noninfected wounds caused by clean objects may undergo primary closure up to 18 hours from the time of injury. Continue to do this until the skin opening has closed. Dog and cat bites in an immunocompromised host and those that involve the face or hand, periosteum, or joint capsule are typically treated with a beta-lactam antibiotic or beta-lactamase inhibitor (e.g., amoxicillin/clavulanate [Augmentin]).5 In patients allergic to penicillin, a combination of trimethoprim/sulfamethoxazole or a quinolone with clindamycin or metronidazole (Flagyl) can be used. They result when oil-producing or sweat glands are obstructed, and bacteria are trapped. If a gauze packing was placed inside the abscess pocket, you may be told to remove it yourself. Empiric antibiotic treatment should be based on the potentially causative organism. Doral Urgent Care. Infected Pilonidal Cyst (Incision & Drainage) - Fairview (2018). National Library of Medicine Keep the area clean and protected from further injury. Current wound care practices recommend maintaining a moist wound bed to aid in healing.7,8 Wounds should be occluded with an appropriate dressing and reassessed periodically for optimal moisture levels. All rights reserved. Continued drainage from the abscess will spoil the dressing and it is therefore necessary to change this at least on a daily basis or more frequently if the dressing becomes particularly soiled. Appointments 216.444.5725. First, depending on the size and depth of the cyst or abscess, the physician will bandage the wound with sterile gauze or will insert a drain to allow the abscess to continue draining as it heals. Incision and drainage of subcutaneous abscesses without the use of packing. Why Hard Lump After Abscess Drained Need Special Attention 2021 Discover how to lessen their appearance or get rid of them permanently. sexual orientation, gender, or gender identity. 2013 Sep;48(9):1962-5. doi: 10.1016/j.jpedsurg.2013.01.027. For very deep abscesses, the doctor might pack the abscess site with gauze that needs to be removed after a few days. 13120 Biscayne Blvd., North Miami 305-585-9210 Schedule an Appointment. hb````0e```b 02:00. All sores should heal in 10-14 days. Debridement can be performed using surgical techniques or topical agents that lead to enzymatic breakdown or autolysis of necrotic tissue. If so, it should be removed in 1 to 2 days, or as advised. Practice and instruct in good handwashing and aseptic wound care. Alternatively, a longitudinal incision centered on the volar pad can be performed. Carefully throw away the packing to prevent spreading any infection. doi: 10.2196/resprot.7419. The catheter allows the pus to drain out into a bag and may have to be left in place for up to a week. 0. "RLn/WL/qn["C)X3?"gp4&RO Stopping your antibiotics too early may increase your risk of having the infection return. Most severe wound infections, and moderate infections in high-risk patients, require initial parenteral antibiotics, with transition to oral antibiotics after therapeutic response. 2020 Nov;13(11):37-43. Abscess drainage is usually a safe and effective way of treating a bacterial infection of the skin. Be careful not to burn yourself. Treatment of necrotizing fasciitis involves early recognition and surgical debridement of necrotic tissue, combined with high-dose broad-spectrum intravenous antibiotics. Consensus guidelines recommend trimethoprim/sulfamethoxazole or tetracycline if methicillin-resistant S. aureus infection is suspected,30 although a Cochrane review found insufficient evidence that one antibiotic was superior for treating methicillin-resistant S. aureuscolonized nonsurgical wounds.36, Moderate wound infections in immunocompromised patients and severe wound infections usually require parenteral antibiotics, with possible transition to oral agents.30,31 The choice of agent should be based on the potentially causative organism, history, and local antibiotic resistance patterns. Apply Vaseline to wound. 2004 Feb;23(2):123-7. doi: 10.1097/01.inf.0000109288.06912.21. Ideally, make second small (4-5mm) incision within 4 cm of the first. Anorectal Abscess Surgery: What to Expect at Home - Alberta They can be drained surgically, carried out under general or local anaesthetic, depending on location of abscess and patient tolerance. Abscess Drainage: Procedures, Recovery, Recurrence - Healthline After the pus has drained out, your doctor cleans out the pocket with a sterile saline solution. Some recent evidence has suggested that routinely performed treatment modalities may not be beneficial. If drainage persists then repack the wound and have the patient return in 24 to 48 hours for a wound check. Wound Care Bandage: Leave bandage in place for 24 hours. Clean area with soap and water in shower. You should see a doctor if the following symptoms develop: A doctor can usually diagnose a skin abscess by examining it. S. aureus and streptococci are responsible for most simple community-acquired SSTIs. Service. I prefer to use a #15 blade scalpel rather than the traditional #11 bladebut either will work. hbbd```b``"A$da`8&A$-}Drt`h hf k5@0{"'t5P0 0r It offers faster recovery than open surgical drainage. Incision and Drainage of Abscesses - Procedure and Recovery Diabetic lower limb infections, severe hospital-acquired infections, necrotizing infections, and head and hand infections pose higher risks of mortality and functional disability.9, Patients with simple SSTIs present with erythema, warmth, edema, and pain over the affected site. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you. The https:// ensures that you are connecting to the Certain medical conditions or other factors may increase your risk of perineal abscesses. After your first in-studio acne treatment . DIET: Diet as desired unless otherwise instructed. Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections. -----View Our. Its usually triggered by a bacterial infection. exclude or treat people differently because of race, color, national origin, age, disability, sex, After incision and drainage, treat with antistaphylococcal antibiotics and warm soaks and have frequent follow-up visits. Less commonly, percutaneous abscess drainage may be used . 00:30. 8600 Rockville Pike Abscess incision and drainage - SAEM FOIA About 1 in 15 of these women can develop breast abscesses. Incision & Draining of Abscess Care | U.S. Dermatology Partners Rhle A, Oehme F, Brnert K, Fourie L, Babst R, Link BC, Metzger J, Beeres FJ. A dressing that gets wet will need to be changed. You have a fever or chills. stream The abscess may be a result of recent surgery or secondary to an infection such as appendicitis. Epub 2020 Nov 1. Incision and Drainage Procedure to Treat Abscesses - Verywell Health How long does it take for an abscess to heal? You should also be able to answer questions about your symptoms, such as: To identify the type of infection you have, your doctor may send pus drained from the area to a lab for analysis. Abscess Nursing Diagnosis and Nursing Care Plan - NurseStudy.Net The Best 8 Home Remedies for Cysts: Do They Work? Lacerations, abrasions, burns, and puncture wounds are common in the outpatient setting. You may feel resistance as the incision is initiated. Encourage and provide perineal care. Within a week, your doctor will remove the dressing and any inside packing to examine the wound during a follow-up appointment. Billing and Coding: Incision and Drainage of Abscess of Skin Perianal abscess requires formal incision of the abscess to allow drainage of the pus. Perianal Abscess: vs. Hemorrhoid, Causes & Treatment, Surgery Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up. Tissue adhesives are not recommended for wounds with complex jagged edges or for those over high-tension areas (e.g., hands, joints).15 Tissue adhesives are easy to use, require no anesthesia and less procedure time, and provide good cosmetic results.1517. The recommendations apply to all adults and children with uncomplicated skin abscesses who present to the emergency department or family physician offices, including those with abscesses of all . A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Search dates: May 7, 2014, through May 27, 2015. If your abscess was opened with an Incision and Drainage: Keep the abscess covered 24 hours a day, removing bandages once daily to wash with warm soap and water. Epub 2009 May 5. It is not intended as medical advice for individual conditions or treatments. LESS THAN. The diagnosis is based on clinical evaluation. Discover home remedies for boils, such as a warm compress, oil, and turmeric. Three randomized control trials (RCT) and one observational study investigated wound packing versus no packing following I&D. Patients may prefer irrigation with warm fluids. In contrast, complicated infections can be mono- or polymicrobial and may present with systemic inflammatory response syndrome. Bethesda, MD 20894, Web Policies There is no evidence that antiseptic irrigation is superior to sterile saline or tap water. Our website services, content, and products are for informational purposes only. Magnetic resonance imaging is highly sensitive (100%) for necrotizing fasciitis; specificity is lower (86%).24 Extensive involvement of the deep intermuscular fascia, fascial thickening (more than 3 mm), and partial or complete absence of signal enhancement of the thickened fasciae on postgadolinium images suggest necrotizing fasciitis.25 Adding ultrasonography to clinical examination in children and adolescents with clinically suspected SSTI increases the accuracy of diagnosing the extent and depth of infection (sensitivity = 77.6% vs. 43.7%; specificity = 61.3% vs. 42.0%, respectively).26, The management of SSTIs is determined primarily by their severity and location, and by the patient's comorbidities (Figure 5). Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. $U? Regardless of supplemental post-procedural treatment, all studies demonstrate high rates of clinical cure following I&D. Follow up with your healthcare provider, or as advised. Your doctor may also prescribe antibiotic therapy to help your body fight off the initial infection and prevent subsequent infections. endstream endobj startxref Irrigate and get the pus out! This content is owned by the AAFP. This can help speed up the healing process. The goal of treatment is to eliminate the bacteria without further damage to the underlying tissue. A Cochrane review did not establish the superiority of any one pathogen-sensitive antibiotic over another in the treatment of MRSA SSTI.35 Intravenous antibiotics may be continued at home under close supervision after initiation in the hospital or emergency department.36 Antibiotic choices for severe infections (including MRSA SSTI) are outlined in Table 6.5,27, For polymicrobial necrotizing infections; safety of imipenem/cilastatin in children younger than 12 years is not known, Common adverse effects: anemia, constipation, diarrhea, headache, injection site pain and inflammation, nausea, vomiting, Rare adverse effects: acute coronary syndrome, angioedema, bleeding, Clostridium difficile colitis, congestive heart failure, hepatorenal failure, respiratory failure, seizures, vaginitis, Children 3 months to 12 years: 15 mg per kg IV every 12 hours, up to 1 g per day, Children: 25 mg per kg IV every 6 to 12 hours, up to 4 g per day, Children: 10 mg per kg (up to 500 mg) IV every 8 hours; increase to 20 mg per kg (up to 1 g) IV every 8 hours for Pseudomonas infections, Used with metronidazole (Flagyl) or clindamycin for initial treatment of polymicrobial necrotizing infections, Common adverse effects: diarrhea, pain and thrombophlebitis at injection site, vomiting, Rare adverse effects: agranulocytosis, arrhythmias, erythema multiforme, Adults: 600 mg IV every 12 hours for 5 to 14 days, Dose adjustment required in patients with renal impairment, Rare adverse effects: abdominal pain, arrhythmias, C. difficile colitis, diarrhea, dizziness, fever, hepatitis, rash, renal insufficiency, seizures, thrombophlebitis, urticaria, vomiting, Children: 50 to 75 mg per kg IV or IM once per day or divided every 12 hours, up to 2 g per day, Useful in waterborne infections; used with doxycycline for Aeromonas hydrophila and Vibrio vulnificus infections, Common adverse effects: diarrhea, elevated platelet levels, eosinophilia, induration at injection site, Rare adverse effects: C. difficile colitis, erythema multiforme, hemolytic anemia, hyperbilirubinemia in newborns, pulmonary injury, renal failure, Adults: 1,000 mg IV initial dose, followed by 500 mg IV 1 week later, Common adverse effects: constipation, diarrhea, headache, nausea, Rare adverse effects: C. difficile colitis, gastrointestinal hemorrhage, hepatotoxicity, infusion reaction, Adults and children 12 years and older: 7.5 mg per kg IV every 12 hours, For complicated MSSA and MRSA infections, especially in neutropenic patients and vancomycin-resistant infections, Common adverse effects: arthralgia, diarrhea, edema, hyperbilirubinemia, inflammation at injection site, myalgia, nausea, pain, rash, vomiting, Rare adverse effects: arrhythmias, cerebrovascular events, encephalopathy, hemolytic anemia, hepatitis, myocardial infarction, pancytopenia, syncope, Adults: 4 mg per kg IV per day for 7 to 14 days, Common adverse effects: diarrhea, throat pain, vomiting, Rare adverse effects: gram-negative infections, pulmonary eosinophilia, renal failure, rhabdomyolysis, Children 8 years and older and less than 45 kg (100 lb): 4 mg per kg IV per day in 2 divided doses, Children 8 years and older and 45 kg or more: 100 mg IV every 12 hours, Useful in waterborne infections; used with ciprofloxacin (Cipro), ceftriaxone, or cefotaxime in A. hydrophila and V. vulnificus infections, Common adverse effects: diarrhea, photosensitivity, Rare adverse effects: C. difficile colitis, erythema multiforme, liver toxicity, pseudotumor cerebri, Adults: 600 mg IV or orally every 12 hours for 7 to 14 days, Children 12 years and older: 600 mg IV or orally every 12 hours for 10 to 14 days, Children younger than 12 years: 10 mg per kg IV or orally every 8 hours for 10 to 14 days, Common adverse effects: diarrhea, headache, nausea, vomiting, Rare adverse effects: C. difficile colitis, hepatic injury, lactic acidosis, myelosuppression, optic neuritis, peripheral neuropathy, seizures, Children: 10 to 13 mg per kg IV every 8 hours, Used with cefotaxime for initial treatment of polymicrobial necrotizing infections, Common adverse effects: abdominal pain, altered taste, diarrhea, dizziness, headache, nausea, vaginitis, Rare adverse effects: aseptic meningitis, encephalopathy, hemolyticuremic syndrome, leukopenia, optic neuropathy, ototoxicity, peripheral neuropathy, Stevens-Johnson syndrome, For MSSA, MRSA, and Enterococcus faecalis infections, Common adverse effects: headache, nausea, vomiting, Rare adverse effects: C. difficile colitis, clotting abnormalities, hypersensitivity, infusion complications (thrombophlebitis), osteomyelitis, Children: 25 mg per kg IM 2 times per day, For necrotizing fasciitis caused by sensitive staphylococci, Rare adverse effects: anaphylaxis, bone marrow suppression, hypokalemia, interstitial nephritis, pseudomembranous enterocolitis, Adults: 2 to 4 million units penicillin IV every 6 hours plus 600 to 900 mg clindamycin IV every 8 hours, Children: 60,000 to 100,000 units penicillin per kg IV every 6 hours plus 10 to 13 mg clindamycin per kg IV per day in 3 divided doses, For MRSA infections in children: 40 mg per kg IV per day in 3 or 4 divided doses, Combined therapy for necrotizing fasciitis caused by streptococci; either drug is effective in clostridial infections, Adverse effects from penicillin are rare in nonallergic patients, Common adverse effects of clindamycin: abdominal pain, diarrhea, nausea, rash, Rare adverse effects of clindamycin: agranulocytosis, elevated liver enzyme levels, erythema multiforme, jaundice, pseudomembranous enterocolitis, Children: 60 to 75 mg per kg (piperacillin component) IV every 6 hours, First-line antimicrobial for treating polymicrobial necrotizing infections, Common adverse effects: constipation, diarrhea, fever, headache, insomnia, nausea, pruritus, vomiting, Rare adverse effects: agranulocytosis, C. difficile colitis, encephalopathy, hepatorenal failure, Stevens-Johnson syndrome, Adults: 10 mg per kg IV per day for 7 to 14 days, For MSSA and MRSA infections; women of childbearing age should use 2 forms of birth control during treatment, Common adverse effects: altered taste, nausea, vomiting, Rare adverse effects: hypersensitivity, prolonged QT interval, renal insufficiency, Adults: 100 mg IV followed by 50 mg IV every 12 hours for 5 to 14 days, For MRSA infections; increases mortality risk; considered medication of last resort, Common adverse effects: abdominal pain, diarrhea, nausea, vomiting, Rare adverse effects: anaphylaxis, C. difficile colitis, liver dysfunction, pancreatitis, pseudotumor cerebri, septic shock, Parenteral drug of choice for MRSA infections in patients allergic to penicillin; 7- to 14-day course for skin and soft tissue infections; 6-week course for bacteremia; maintain trough levels at 10 to 20 mg per L, Rare adverse effects: agranulocytosis, anaphylaxis, C. difficile colitis, hypotension, nephrotoxicity, ototoxicity. Because wounds can quickly become infected, the most important aspect of treating a minor wound is irrigation and cleaning. The primary way to treat an abscess is via incision and drainage. Clipboard, Search History, and several other advanced features are temporarily unavailable. Perianal infections, diabetic foot infections, infections in patients with significant comorbidities, and infections from resistant pathogens also represent complicated infections.8. Hearns CW. The wound may drain for the first 2 days. If a gauze packing was placed inside the abscess pocket, you may be told to remove it yourself. Care should be taken to avoid injecting anesthetic into the abscess cavity, as this will increase pressure (and thus pain for the patient) and is unlikely to successfully anesthetize. For example, a perianal abscess almost exclusively general anaesthetic (GA) or spinal. Initial antimicrobial choice is empiric, and in simple infections should cover Staphylococcus and Streptococcus species. Cover the wound with a clean dry dressing. All Rights Reserved. MRSA infection. Abscess drainage. Antibiotics may have been prescribed if the infection is spreading around the wound. Wound care instructions from your doctor may include wound repacking, soaking, washing, or bandaging for about 7 to 10 days. Language assistance services are availablefree of charge. Prophylactic antibiotic use may reduce the incidence of infection in human bite wounds. Care An abscess incision and drainage (I and D) is a procedure to drain pus from an abscess and clean it out so it can heal. V+/T >`xG; |L\rC/.)cOs[&`(&I{WVj6}\,2a Gently pull packing strip out -1 inch and cut with scissors. Incision and drainage (I&D) is a widely used procedure in various care settings, including emergency departments and outpatient clinics.
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