US and FB in the ED US and FB in the ED Louise Rang MD FRCPC RDMS Emergency Ultrasound Program...

US and FB in the EDUS and FB in the ED

Louise Rang MD FRCPC RDMSLouise Rang MD FRCPC RDMSEmergency Ultrasound Program DirectorEmergency Ultrasound Program Director

Queen’s University, Kingston ONQueen’s University, Kingston ON© Louise Rang 2008© Louise Rang 2008

Louise Rang MD FRCPC RDMSLouise Rang MD FRCPC RDMSEmergency Ultrasound Program DirectorEmergency Ultrasound Program Director

Queen’s University, Kingston ONQueen’s University, Kingston ON© Louise Rang 2008© Louise Rang 2008

OutlineOutline

Where’s the evidence? How is it useful? What do various FB look like? How do I do it? Tips & tricks

Why does it matter?Why does it matter?

Retained FB is Common Time consuming #4 cause of ED malpractice

What tools do we have? 1What tools do we have? 1 Pro Con

Xray Readily availableGood for even small radio-opaque FBwith skin markers, some help for localisation

poor for plastic, woodno dynamic localisationSome radiation

CT less available”a big gun”poorer for small non-radio-opaque FBno help with localisation

Local Exploration

can diagnose & treat at same time

time consuminginvasivepatient trauma?false sense of security

What tools do we have? 2What tools do we have? 2

Ultrasound! Available No radiation Dynamic Good for many types of FB (>2mm) May show other important structures

ConsCons poor for smaller FB <1-2mm Operator dependent need linear high frequency probe

poor for smaller FB <1-2mm Operator dependent need linear high frequency probe

How do they compare in accuracy?

sensitivity specificity

Xray glass, metalXray other

95%low

CT 0-60%US radiologyUS ED

70-80%50-95%

86%50-90%

Where is the evidence that we can do it?

Hill Ann EM 97 53 FB implanted in amputated

human legs + 27 control punctures2h practice sessionWood sn 93%Plastic sn 73%Sp 59%

Hill Ann EM 97 53 FB implanted in amputated

human legs + 27 control punctures2h practice sessionWood sn 93%Plastic sn 73%Sp 59%

How long does it take to learn?

Hill AnnEM 97 2h training session

Jansen Ann EM 95, 10 min talk in intro course Accuracy with prior US exp= 80% Accuracy with no prior US exp=65%

Hill AnnEM 97 2h training session

Jansen Ann EM 95, 10 min talk in intro course Accuracy with prior US exp= 80% Accuracy with no prior US exp=65%

How is US useful?How is US useful?

3 basic aspects: 1. Diagnosis of retained FB 2. Identification of FB location 3. Assistance with removal

Unlike any other modality!

3 basic aspects: 1. Diagnosis of retained FB 2. Identification of FB location 3. Assistance with removal

Unlike any other modality!

Images of FBImages of FB

Wood Needle Metal

fragment Glass

Wood Needle Metal

fragment Glass

WoodWood

Characteristics- woodCharacteristics- wood

Shadow behind

Echogenic

NeedleNeedle

video waterbath_needle long.avi

QuickTime™ and a decompressor

are needed to see this picture.

Characteristics- NeedleCharacteristics- Needle

echogenicreverb

Metal FragmentsMetal Fragments

Characteristics- MetalCharacteristics- Metal

echogenic

comet tail

echogenic

Slight shadow

GlassGlass

Glass 2Glass 2

Image used with permission, Blue Phantom IncImage used with permission, Blue Phantom Inc

Characteristics- GlassCharacteristics- Glass

++variable ++variable

Acoustic enhancement

echogenic

echogenicreverb

Other- springOther- spring

Ok ,so I know it’s thereOk ,so I know it’s there

How Do I Remove It?How Do I Remove It?

Equipment Settings Static vs dynamic Techniques of removal

EquipmentEquipment

Linear probe Procedure equipment nearby Patient/MD positioning

Machine settingsMachine settings

Frequency/ “res” setting Focus

Dead ZoneDead Zone

3.5MHz 12MHz3.5MHz 12MHz

StandoffsStandoffs

gelgel

WaterbathWaterbath

No gel or skin contact required! No gel or skin contact required!

Waterbath TechniqueWaterbath Technique

Improves sensitivity Gel sn 70% sp90% Waterbath sn 92% sp93%

Improves time of search Gel 22min Waterbath 9min

Improves sensitivity Gel sn 70% sp90% Waterbath sn 92% sp93%

Improves time of search Gel 22min Waterbath 9min

ComparisonComparison

Gel Waterbath

Static vs DynamicStatic vs Dynamic

Xmarks the spot Xmarks the spot

Removal Technique Removal Technique

1. 1 or 2 needles 1. 1 or 2 needles

Removal TechniqueRemoval Technique

embed: needle movie copy.mov

Removal TechniqueRemoval Technique

embed: Fb removal-r needle,

glass1copy.avi

embed: Fb removal-r needle,

glass1copy.avi

Placement of second needle

embed: Fb removal, L needle,

glass2copy.avi

embed: Fb removal, L needle,

glass2copy.avi

2. Hemostat2. Hemostat

embed: hemostat movie copy.mov

Embed; fb removal long copy.avi

Embed; fb removal long copy.avi QuickTime™ and a

decompressorare needed to see this picture.

Embed: fb removal trans forceps

copy.avi

Embed: fb removal trans forceps

copy.avi

Tips & Tricks- MachineTips & Tricks- Machine

Consider sterile gel Beware the dead zone

High ƒ; alternatives Mark center of probe Sharpie marker

Consider sterile gel Beware the dead zone

High ƒ; alternatives Mark center of probe Sharpie marker

Tips and Tricks- ID & LocalisationTips and Tricks- ID & Localisation

Move slowly & methodicallySeveral different angles

Air Size matters Neg scan ≠no FB

Move slowly & methodicallySeveral different angles

Air Size matters Neg scan ≠no FB

PitfallsPitfalls

False Positives Normal anatomy

False Negatives Too small Too fast Too superficial Too much stuff around

False Positives Normal anatomy

False Negatives Too small Too fast Too superficial Too much stuff around

Tips and Tricks- RemovalTips and Tricks- Removal

Set time limit Remember anatomy 2 needles are better than 1

the fine print…the fine print…Trautlein Trautlein JJ, Lambert RL, Miller J: Malpractice in the emergency department -- Review of 200 JJ, Lambert RL, Miller J: Malpractice in the emergency department -- Review of 200

cases. Ann Emerg Med September 1984 (Part 1); I3: 709-711cases. Ann Emerg Med September 1984 (Part 1); I3: 709-711 Jacobson JA Jacobson JA Wooden foreign bodies in soft tissue: detection at US.Wooden foreign bodies in soft tissue: detection at US.- - RadiologyRadiology - 01-JAN- - 01-JAN-

1998; 206(1): 45-81998; 206(1): 45-8Hill Ultrasound for detection of foreign bodies in human tissue. Ann Emerg Med Mar 97 Hill Ultrasound for detection of foreign bodies in human tissue. Ann Emerg Med Mar 97

28(3)352-35628(3)352-356Bray P Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand J Bray P Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand J

Hand Surg (Am) 1990:19:701-703 Hand Surg (Am) 1990:19:701-703 Jansen Learning ultrasound for detection of foreign bodies: How difficult? (abst) Ann Emerg Jansen Learning ultrasound for detection of foreign bodies: How difficult? (abst) Ann Emerg

Med 46(3) Sept 2005 S21Med 46(3) Sept 2005 S21Blaivas, M et al. Water bath evaluation technique for emergency ultrasound of painful superficial Blaivas, M et al. Water bath evaluation technique for emergency ultrasound of painful superficial

structuresstructuresAmerican Journal of Emergency MedicineAmerican Journal of Emergency Medicine - Volume 22, Issue 7 (November - Volume 22, Issue 7 (November 2004)2004)

Raio CC et al. Can emergency ultrasonographers utilise a waterbath to more accurately identify Raio CC et al. Can emergency ultrasonographers utilise a waterbath to more accurately identify superficial soft tissue foreign bodies? (Abst) Ann Emerg Med 46(3) Sept 2005 S28superficial soft tissue foreign bodies? (Abst) Ann Emerg Med 46(3) Sept 2005 S28

Teisen, HG. Sonographische Feinlocalisation von fremdkorpen. Ultraschall1988: 9:135-137-- Teisen, HG. Sonographische Feinlocalisation von fremdkorpen. Ultraschall1988: 9:135-137-- translated in Ma & Mateer, Emergency Ultrasoundtranslated in Ma & Mateer, Emergency Ultrasound

Dewitz A and Frazee B. Dewitz A and Frazee B. Soft Tissue ApplicationsSoft Tissue Applications in Emergency Ultrasound ed MaOJ and Mateer in Emergency Ultrasound ed MaOJ and Mateer J McGraw- Hill 2003.J McGraw- Hill 2003.

Frazee B and White DAE Frazee B and White DAE Soft Tissue UltrasoundSoft Tissue Ultrasound in Practical Guide to Emergency Ultrasound in Practical Guide to Emergency Ultrasound ed CosbyK and Kendall JL Lippincott 2006ed CosbyK and Kendall JL Lippincott 2006

Trautlein Trautlein JJ, Lambert RL, Miller J: Malpractice in the emergency department -- Review of 200 JJ, Lambert RL, Miller J: Malpractice in the emergency department -- Review of 200