Emergency Medicine Ultrasound (EMUS) in the management of adults with radiolucent foreign bodies
Date First Published:
December 10, 2015
Last Updated:
November 4, 2016
Report by:
Dr Liam Swains, StR Emergency Medicine (Derriford Hospital)
Search checked by:
Dr Stephen Fordham, Derriford Hospital
Three-Part Question:
In [adult patients with wooden foreign body], can [Emergency Medicine Ultrasound] be effectively utilised for the [removal the foreign body] in the ED?
Clinical Scenario:
A 32 otherwise fit and well man attends the ED two hours after running his hand along an old wooden broom. He sustained a penetrating wound from a large wood splinter which he thought he had removed. He now complains of ongoing sharp sensation in the ulnar border of his palm on palpation and movement.
A radiograph by the triage nurse shows no foreign body but you know that wood is radiolucent 85-100% of the time.
You consider whether ED ultrasound might be useful
A radiograph by the triage nurse shows no foreign body but you know that wood is radiolucent 85-100% of the time.
You consider whether ED ultrasound might be useful
Search Strategy:
MEDLINE, EMBASE and CINAHL database accessed via NICE portal 1946-10/2015.
[Pocus.af OR Ultrasound.af OR Ultrasonography.af OR
Sonography.af OR expULTRASONOGRAPHY/] AND ["foreign body".af OR splinter.af OR expWOOD/ OR *wood/ OR wood*.af OR expFOREIGN BODIES/ OR *foreign bodies/] AND [EMERGENCY SERVICE, HOSPITAL/ OR expEMERGENCY OR SERVICE, HOSPITAL/ OR *EMERGENCY SERVICE, HOSPITAL/ OR department.af OR doctor.af OR physician.af OR nurse.af OR practitioner.af] LIMIT to Human,Young adult, Adult, Middle aged, Aged, Aged 80 and over, English.
[Pocus.af OR Ultrasound.af OR Ultrasonography.af OR
Sonography.af OR expULTRASONOGRAPHY/] AND ["foreign body".af OR splinter.af OR expWOOD/ OR *wood/ OR wood*.af OR expFOREIGN BODIES/ OR *foreign bodies/] AND [EMERGENCY SERVICE, HOSPITAL/ OR expEMERGENCY OR SERVICE, HOSPITAL/ OR *EMERGENCY SERVICE, HOSPITAL/ OR department.af OR doctor.af OR physician.af OR nurse.af OR practitioner.af] LIMIT to Human,Young adult, Adult, Middle aged, Aged, Aged 80 and over, English.
Search Details:
Databases, Google Scholar, Cochrane collaboration and bibliographies searched and researchers contacted by personal email.
Outcome:
5 significant research papers found
9 Case reports identified
9 Case reports identified
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Ultrasound for the detection of foreign bodies. Schlager D, Sanders AB, Wiggins D, Boren W. 1991 USA | Experimental model | Controlled Blinded Bench top experiental study | Ability of EM physician to detect foreign bodies in simulated wounds in cubes of beef tissue | Sens 98% Spec 98% PPV 98% NPV 98% | Non human tissues No gold standard No record of foreign body depth |
| Bedside ultrasound for the detection of soft tissue foreign bodies: A cadaveric study. Crystal CS et al. 2009 USA | Cadaveric Study | Prospective, randomised, blinded cadaveric study of ultrasound detection of foreign bodies in the tissues | Correct identification by ED physician sonographer of wounds containing simulated foreign body and 'control' empty wounds | Sens 52.6% (CI 48.9-56.2) Spec 47.2% (CI 39.9-54.5) PPV 79.9% (CI 76.3-83.5) NPV 20% (CI 16.2-23.7) PLR 1.0 (CI 0.81-1.24) NLR 1.0 (CI 1.28-0.80) | Cadaveric tissues Ultrasound used in isolation Some very deep foreign bodies Hands and feet omitted from imaging |
| Ultrasound for the detection of foreign bodies in human tissue Hill R, Conron R, Greissinger P, Heller M. 1997 USA | Recently amputated human legs | Pragmatic, randomised, blinded, cadaveric study | detection of presence or absence of FB | Overall Sens 83%. For wood: Sens 93% Spec 59% Accuratcy of sonographer similar - Consultant 77% Registrar 70%. | Only 2 sonographers, No gold standard imaging Dead diseased tissue (calcification mistaken for FB) All large FB (2cm) |
| The comparative accuracy of radiolucent foreign body detection using ultrasonography Orlinsky M, Knittel P, Feit T, Chan L, Mandavia D 2000 USA | Experimental study on chicken thigh tissue | Randomised single blinded bench top experimental study | Detection and orientation of Foreign bodies in the tissue by Radiology consultant, ultrasound technician and EM registrar | Consultant: Sens, Spec, PPV and NPV all 83% (CI 72-93). US Tech: Sens and Spec 85% (CI 78-92), PPV 86% (CI 79-93), NPV 84% (CI 77-92). EM Registrar Sens 74% (CI 67-81), Spec 87% (CI 82-92), PPV 85% (CI 79-91), NPV 77% (CI 71-83). | Non human tissue Fatigued sonographers Single radiologist comparison Tissues degraded throughout the experiment |
| Accuracy of bedside ultrasound for the detection of soft tissue foreign bodies by emergency doctors Nienaber A, Harvey M, Cave G. 2010 New Zealand | Experimental study using porcine belly | Prospective, randomised, blinded, bench-top diagnostic study. | Detection of presence or absence of single and multiple Foreign bodies by 6 x EM Consultants and 14 x Registrars | 400 Scans. Overall Consultant Sens 96.7%, Spec 70.0%, PPV 76.3%, NPV 95.5%. Overall Registrar Sens 85.7%, Spec 82.9%, PPV 83.3%, NPV 85.3%. | Non human tissues No gold standard imaging comparator Deep FB placement High frequency transducer may not be widely available Very heterogeneous sonographer experience (20 mins to 5+ years) |
| Bedside ultrasound aids identification and removal of cutaneous foreign bodies: A case series Budhram GR, Schmunk JC. 2014 USA | Emergency department patients | Non consecutive case series | ED physician diagnosis and removal of FB | ED physician successfully removed 2 of 3 FB, with one surgical referral required | Small number of cases Experience of sonographers not declared Single wooden FB reported in the series |
| Detection of soft-tissue foreign bodies by plain radiography, xerography, computed tomography and ultrasonography. Ginsberg MJ, EllisGL, Flom LL, 1990 USA | Laboratory experimental report | In vitro comparison of XR, Xerography, CT, USS in detection of wood, glass and plastic FB placed between strips of steak | Positive identifcation of foreign body by imaging technique | Ultrasonography most reliably detected radiolucent FB and carried no ionising radiation exposure. | Age of paper Non human tissues Experience of sonographer not reported Poor tissue comparison Xerography rarely used due to 20x radiation dose Insuffiently generalisable |
| Ultrasound in the Emergency Department: Detection of wooden foreign bodies in the soft tissues Graham DD. 2002 USA | Four patients with suspected wooden foreign bodies | Case series | EM physician ultrasound detection of wooden foreign body | Four of four wooden foreign bodies detected and removed in the Emergency department | Small number of cases Single operator No comparator |
| Ultrasound-guided foreign body removal Lee GPC, Chung KL, Kam CW. 2008 Hong Kong | Tertiary referral emergency department patient who had undergone XR examination and failed surgical exploration for wooden foreign body | Case report | Identification and removal of wooden foreign body in ED | Successful identification a | Single case report Experience of sonographer not declared |
| My patient is injured: identifying foriegn bodies with ultrasound Lewis D, Jivraj A, Atkinson P, Jarman R 2015 Canada | Emergency department patient with suspected wooden foreign body | Case report and literature review | ED ultrasound guided detection and removal of foreign body | EM physician Ultrasound can be effective and timely and ED physicians are capable of developing expertise with regular training and audit | Single case report Experience of sonographer not declared No clear methodology, inclusion, exclusion criteria or critical appraisal. |
| Emergency department ultrasound (EDU): clinical adjunct or plaything? McLaughlin R, Collum N, McGovern S, Martyn C, Bowra J. 2005 Ireland | Three patients presenting to regional Emergency department, one with wound and suspected foreign body | Case series | Assessment of ED ultrasound as imaging modality for EM physicians with 1 day ultrasound training | Positive detection of wooden FB not detected on radiography - patient referred for removal. | Single patient case Only in-house non accredited training course attended by sonographers Focus on wider scope of ED ultrasound uses |
| Soft tissue foreign body removal technique using portable ultrasonography Paziana K, Fields JM, Rotte M, Au A, Ku B 2012 USA | Two patients presenting to the Emergency department with suspected wooden foreign bodies | Case series | Assessment nd identification of suspected wooden foreign body | Both foreign bodies detected and removed under direct US, avoiding referral | Limited number of patients Experience of sonographer not reported Hand held ultrasound device used may not be widely available |
| Emergency Ultrasound Perera P, Mandavia D 2008 USA | Single patient presenting to emergency department with suspected wooden foreign body | Case report | EM physician detection of wooden foreign body | Foreign body detected and visualised in deep structures of the hand and referred for surgery | Single patient report Experience of sonographer not declared Published as a teaching case No references or evidence base stated |
| Ultrasound detection of foreign body and gas contamination of a penetrating wound Testa A, Giannuzzi R, Zirio G, La Greca A, Gentilioni Silveri N. 2009 Italy | Single patient attending Emergency department with suspected foreign body | Case report | Single case report Experience of sonographer not declared Removal technique not reported Foreign body material not clearly defined Foreign body already identified on radiography |
Author Commentary:
ED physicians quickly develop ultrasound FB detection skills and can demonstrate accuracy of 80% (CI 76-85) compared to radiologist 83% (CI 75-90)
The greater the experience and education of the sonographer, the better the detection rate (albeit modest)
EM ultrasound is best undertaken in an appropriately governed system with regular logged training and scanning exposure.
The greater the experience and education of the sonographer, the better the detection rate (albeit modest)
EM ultrasound is best undertaken in an appropriately governed system with regular logged training and scanning exposure.
Bottom Line:
After limited dedicated teaching, ED physician ultrasound for foreign body detection approaches sufficient sensitivity to be considered clinically useful
References:
- Schlager D, Sanders AB, Wiggins D, Boren W. . Ultrasound for the detection of foreign bodies.
- Crystal CS et al.. Bedside ultrasound for the detection of soft tissue foreign bodies: A cadaveric study.
- Hill R, Conron R, Greissinger P, Heller M.. Ultrasound for the detection of foreign bodies in human tissue
- Orlinsky M, Knittel P, Feit T, Chan L, Mandavia D. The comparative accuracy of radiolucent foreign body detection using ultrasonography
- Nienaber A, Harvey M, Cave G.. Accuracy of bedside ultrasound for the detection of soft tissue foreign bodies by emergency doctors
- Budhram GR, Schmunk JC.. Bedside ultrasound aids identification and removal of cutaneous foreign bodies: A case series
- Ginsberg MJ, EllisGL, Flom LL, . Detection of soft-tissue foreign bodies by plain radiography, xerography, computed tomography and ultrasonography.
- Graham DD.. Ultrasound in the Emergency Department: Detection of wooden foreign bodies in the soft tissues
- Lee GPC, Chung KL, Kam CW.. Ultrasound-guided foreign body removal
- Lewis D, Jivraj A, Atkinson P, Jarman R. My patient is injured: identifying foriegn bodies with ultrasound
- McLaughlin R, Collum N, McGovern S, Martyn C, Bowra J.. Emergency department ultrasound (EDU): clinical adjunct or plaything?
- Paziana K, Fields JM, Rotte M, Au A, Ku B. Soft tissue foreign body removal technique using portable ultrasonography
- Perera P, Mandavia D. Emergency Ultrasound
- Testa A, Giannuzzi R, Zirio G, La Greca A, Gentilioni Silveri N.. Ultrasound detection of foreign body and gas contamination of a penetrating wound