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US and FB in the ED US and FB in the ED Louise Rang MD FRCPC RDMS Emergency Ultrasound Program Director Queen’s University, Kingston ON © Louise Rang.

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Presentation on theme: "US and FB in the ED US and FB in the ED Louise Rang MD FRCPC RDMS Emergency Ultrasound Program Director Queen’s University, Kingston ON © Louise Rang."— Presentation transcript:

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2 US and FB in the ED US and FB in the ED Louise Rang MD FRCPC RDMS Emergency Ultrasound Program Director Queen’s University, Kingston ON © Louise Rang 2008 Louise Rang MD FRCPC RDMS Emergency Ultrasound Program Director Queen’s University, Kingston ON © Louise Rang 2008

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

4 Why does it matter?  Retained FB is  Common  Time consuming  #4 cause of ED malpractice cases  Retained FB is  Common  Time consuming  #4 cause of ED malpractice cases

5 What tools do we have? 1 Pro  Con  Xray  Readily available  Good for even small radio-opaque FB  with skin markers, some help for localisation  poor for plastic, wood  no dynamic localisation  Some radiation CT  less available  ”a big gun”  poorer for small non-radio-opaque FB  no help with localisation Local Exploration  can diagnose & treat at same time  time consuming  invasive  patient trauma  ?false sense of security

6 What tools do we have? 2  Ultrasound!   Available   No radiation   Dynamic   Good for many types of FB (>2mm)   May show other important structures  Ultrasound!   Available   No radiation   Dynamic   Good for many types of FB (>2mm)   May show other important structures

7 Cons   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

8 How do they compare in accuracy? sensitivityspecificity Xray glass, metal Xray other 95% low CT0-60% US radiology US ED 70-80% 50-95% 86% 50-90%

9 Where is the evidence that we can do it?  Hill Ann EM 97  53 FB implanted in amputated human legs + 27 control punctures  2h practice session  Wood sn 93%  Plastic sn 73%  Sp 59%  Hill Ann EM 97  53 FB implanted in amputated human legs + 27 control punctures  2h practice session  Wood sn 93%  Plastic sn 73%  Sp 59%

10 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%

11 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!

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13 Images of FB  Wood  Needle  Metal fragment  Glass  Wood  Needle  Metal fragment  Glass

14 Wood

15

16 Characteristics- wood Shadow behind Echogenic

17 Needle

18  video waterbath_needl e long.avi

19 Characteristics- Needle echogenic reverb

20 Metal Fragments

21 Characteristics- Metal echogenic comet tail echogenic Slight shadow

22 Glass

23 Glass 2 Image used with permission, Blue Phantom Inc

24 Characteristics- Glass  ++variable Acoustic enhancement echogenic reverb

25 Other- spring

26 Ok,so I know it’s there

27 How Do I Remove It?  Equipment  Settings  Static vs dynamic  Techniques of removal  Equipment  Settings  Static vs dynamic  Techniques of removal

28 Equipment  Linear probe  Procedure equipment nearby  Patient/MD positioning  Linear probe  Procedure equipment nearby  Patient/MD positioning

29 Machine settings  Frequency/ “res” setting  Focus  Frequency/ “res” setting  Focus

30 Dead Zone 3.5MHz 12MHz

31 Standoffs gel

32 Waterbath  No gel or skin contact required!

33 Waterbath 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

34 Comparison Gel Waterbath

35 Static vs Dynamic  Xmarks the spot

36 Removal Technique  1. 1 or 2 needles probe

37 Removal Technique embed: needle movie copy.mov

38 Removal Technique embed: Fb removal-r needle, glass1copy.avi embed: Fb removal-r needle, glass1copy.avi

39 Placement of second needle embed: Fb removal, L needle, glass2copy.avi embed: Fb removal, L needle, glass2copy.avi

40 2. Hemostat embed: hemostat movie copy.mov

41  Embed; fb removal long copy.avi

42  Embed: fb removal trans forceps copy.avi  Embed: fb removal trans forceps copy.avi

43 Tips & 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

44 Tips and Tricks- ID & Localisation  Move slowly & methodically  Several different angles  Air  Size matters  Neg scan ≠no FB  Move slowly & methodically  Several different angles  Air  Size matters  Neg scan ≠no FB

45 Pitfalls  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

46 Tips and Tricks- Removal  Set time limit  Remember anatomy  2 needles are better than 1  Set time limit  Remember anatomy  2 needles are better than 1 1.

47 the fine print… Trautlein JJ, Lambert RL, Miller J: Malpractice in the emergency department -- Review of 200 cases. Ann Emerg Med September 1984 (Part 1); I3: Jacobson JA Wooden foreign bodies in soft tissue: detection at US. - Radiology - 01-JAN- 1998; 206(1): 45-8 Jacobson JA Wooden foreign bodies in soft tissue: detection at US. - Radiology - 01-JAN- 1998; 206(1): 45-8 Hill Ultrasound for detection of foreign bodies in human tissue. Ann Emerg Med Mar 97 28(3) Bray P Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand J Hand Surg (Am) 1990:19: Jansen Learning ultrasound for detection of foreign bodies: How difficult? (abst) Ann Emerg Med 46(3) Sept 2005 S21 Blaivas, M et al. Water bath evaluation technique for emergency ultrasound of painful superficial structuresAmerican Journal of Emergency Medicine - Volume 22, Issue 7 (November 2004) 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 S28 Teisen, HG. Sonographische Feinlocalisation von fremdkorpen. Ultraschall1988: 9: translated in Ma & Mateer, Emergency Ultrasound Dewitz A and Frazee B. Soft Tissue Applications in Emergency Ultrasound ed MaOJ and Mateer J McGraw- Hill Frazee B and White DAE Soft Tissue Ultrasound in Practical Guide to Emergency Ultrasound ed CosbyK and Kendall JL Lippincott 2006 Trautlein JJ, Lambert RL, Miller J: Malpractice in the emergency department -- Review of 200 cases. Ann Emerg Med September 1984 (Part 1); I3: Jacobson JA Wooden foreign bodies in soft tissue: detection at US. - Radiology - 01-JAN- 1998; 206(1): 45-8 Jacobson JA Wooden foreign bodies in soft tissue: detection at US. - Radiology - 01-JAN- 1998; 206(1): 45-8 Hill Ultrasound for detection of foreign bodies in human tissue. Ann Emerg Med Mar 97 28(3) Bray P Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand J Hand Surg (Am) 1990:19: Jansen Learning ultrasound for detection of foreign bodies: How difficult? (abst) Ann Emerg Med 46(3) Sept 2005 S21 Blaivas, M et al. Water bath evaluation technique for emergency ultrasound of painful superficial structuresAmerican Journal of Emergency Medicine - Volume 22, Issue 7 (November 2004) 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 S28 Teisen, HG. Sonographische Feinlocalisation von fremdkorpen. Ultraschall1988: 9: translated in Ma & Mateer, Emergency Ultrasound Dewitz A and Frazee B. Soft Tissue Applications in Emergency Ultrasound ed MaOJ and Mateer J McGraw- Hill Frazee B and White DAE Soft Tissue Ultrasound in Practical Guide to Emergency Ultrasound ed CosbyK and Kendall JL Lippincott 2006

48 Questions or Comments?  me   See you at CAEP Ottawa 08!  me   See you at CAEP Ottawa 08!

49  Please consider this shareware, but would you send me an stating that you are using any or all of it? It keeps the university happy…  Please consider this shareware, but would you send me an stating that you are using any or all of it? It keeps the university happy…


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