Bedside ultrasound for the detection of soft tissue foreign bodies: a cadaveric study

The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm³ in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN^® (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%–56.2%), and overall specificity was 47.2% (95% CI 39.9%–54.5%). Positive predictive value was 79.9% (95% CI 76.3%–83.5%), and negative predictive value was 20.0% (95% CI 16.2%–23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% ± 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% ± 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.     

The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED

Background

Presentation of skin and soft tissue infections (SSTIs) to the pediatric emergency department (PED) has increased. Physical examination alone can be inadequate in differentiating cellulitis from an abscess. The purposes of this study were to determine the effect of bedside ultrasound (US) in improving diagnostic accuracy for SSTIs in the PED and to evaluate its effect on the management of patients with SSTIs.

Methods

We conducted a prospective study of a convenience sample of children who presented to an inner-city PED with signs and symptoms of SSTI. The treating physician's pretest opinions regarding the need for incision and drainage and procedural sedation were collected. A bedside US was performed by trained PED physicians to evaluate for cellulitis vs abscess. The treating physician was made aware of the US findings, and the effect on management was recorded.

Results

Sixty-five patients were enrolled, of whom 47 had US-proven abscess and 18 had cellulitis. The sensitivity of US for detection of abscess was 97.5% (95% confidence interval [CI], 90.1%-99.5%), and the specificity was 69.2% (95% CI, 57.8-72.4%). In comparison, the sensitivity for physical examination alone for detection of abscess was 78.7% (95% CI, 71.4%-84.4%), and the specificity was 66.7% (95% CI, 47.6-81.6%). Ultrasound disagreed with clinical examination and changed management in 9 (13.8%) of 65 patients.

Conclusions

Emergency department bedside US improves accuracy in diagnosis of SSTIs. Bedside US changes management in a small but significant number of patients with SSTIs.     

Bedside ultrasound for the detection of diabetic myonecrosis

Diabetic myonecrosis is an uncommon complication of diabetes mellitus. There are fewer than 50 cases reported in the general medical literature. Patients classically complain of the abrupt onset of diffuse anterior thigh pain with no signs of overlying infection or signs of systemic toxicity.Because of the difficulty in diagnosis, most patients endure multiple medical visits until appropriate imaging modalities are obtained. Currently, magnetic resonance imaging (MRI) or tissue biopsy is considered the gold standard for diagnosis. This is the first case reported in the literature of diabetic myonecrosis detected in the ED by bedside ultrasound. We hope that with the continued use of bedside ultrasound, more physicians will be able to determine abnormal tissue architecture allowing for the early detection of diabetic myonecrosis.     

Accuracy of bedside ultrasound for the detection of soft tissue foreign bodies by emergency doctors

Objective: To assess the ability of emergency physicians and emergency trainees to detect soft tissue foreign bodies using typical ultrasound equipment. Methods: Following a 20 min interactive training session, emergency physicians and emergency trainees were assessed on ability to identify subcutaneous foreign bodies (wood, glass, plastic, gravel and metal) embedded in an experimental model containing both sham and real entry point incisions. In the second phase of the experiment accuracy of detection of multiple foreign bodies was assessed in a similar sonographic phantom. Results: Six emergency physicians and 14 emergency trainees performed a total of 400 individual sonographic examinations. Emergency physicians correctly identified 29 of 30 foreign bodies and returned sensitivity, specificity, positive predictive value and negative predictive value of 96.7%, 70%, 76.3% and 95.5%, respectively. Trainees correctly identified 60 of 70 foreign bodies and returned sensitivity, specificity, positive predictive value and negative predictive value of 85.7%, 82.9%, 83.3% and 85.3%. Correct identification of the number of foreign bodies present, when multiple, was low (25% physician vs 36% trainee). Conclusion: These data suggest ultrasound in the hands of emergency doctors might be useful as an initial screening tool for detection of soft tissue foreign bodies.     

Bedside ultrasound of the soft tissue of the face: a case of early Ludwig's angina

A case is reported of a 38-year-old man presenting with early Ludwig's angina. It is difficult to differentiate superficial from deep infections of the face and neck by physical examination alone. The diagnosis of this condition with bedside soft tissue ultrasound of the face is described. Ludwig's angina is an uncommon infection of the deep tissues of the face and neck that usually evolves from more superficial infections such as dental abscesses.     

Predicting observation unit treatment failures in patients with skin and soft tissue infections

Background

Skin and soft tissue infections are a common admission diagnosis to emergency department (ED) observation units (OU). Little is known about which patients fail OU treatment.

Aims

This study evaluates clinical factors of skin or soft tissue infections associated with further inpatient treatment after OU treatment failure.

Methods

A structured retrospective cohort study of consecutive adults treated for abscess or cellulitis in our OU from April 2005 to February 2006 was performed. Records were identified using ICD-9 codes and were abstracted by two trained abstractors using a structured data collection form. Significant variables on univariate analysis P?Results A total of 183 patient charts were reviewed. Four patients with a non-infectious diagnosis were excluded, leaving 179 patients. The median age was 41 (interquartile range: 20–74). Following observation treatment, 38% of patients required admission. The following variables were evaluated for association with failure to discharge home: intravenous drug use, gender, a positive community-acquired methicillin-resistant Staphylococcus aureus culture, age, presence of medical insurance, drainage of an abscess in the ED, diabetes and a white blood cell count (WBC) greater than 15,000. Following multivariate analysis only female gender odds ratio (OR) 2.33 [95% confidence interval (CI): 1.06–5.15] and WBC greater than 15,000 OR 4.06 (95% CI: 1.53–10.74) were significantly associated with failure to discharge.

Conclusions

Among OU patients treated for skin and soft tissue infections, women were twice as likely to require hospitalization and patients with a WBC?>?15,000 on presentation to the ED, regardless of gender, were 4 times more likely to require hospitalization.     

Frequency and yield of blood cultures for observation patients with skin and soft tissue infections

Objectives1) To measure frequency and yield of blood cultures obtained for observation status adult patients with skin and soft tissue infection (SSTI), 2) describe how often blood cultures were performed according to Infectious Diseases Society of America (IDSA) SSTI guideline indications, 3) identify proportion of patients meeting Center for Medicare Services (CMS) sepsis criteria.DesignRetrospective cohort.SettingTertiary academic center.PatientsConsecutive adult observation status patients hospitalized with SSTI between July 2017 and July 2018.MethodsWe measured the proportion and results of blood cultures obtained among the study cohort and proportion of obtained cultures that satisfied IDSA indications.ResultsWe identified 132 observation status patients with SSTI during the study period; 67 (50.8%) had blood cultures drawn. Only 14 (10.6%) patients met IDSA indications for culture; 51 (38.%) met Center for Medicare Services definition for sepsis. We identified two (3.0%) cases of bacteremia and two (3.0%) cases of skin bacteria contamination. In multivariable analysis, only temperature > 38 °C (OR 3.84, 95%CI 1.09–13.60) and white race (OR 2.71, 95%CI 1.21–6.20) were associated with blood culture obtainment; neither meeting IDSA SSTI guideline indications nor meeting CMS sepsis criteria was associated with culture.ConclusionsAmong observation status patients with SSTI, over half had blood cultures drawn, though 10% satisfied guideline indications for culture. The proportion of cultures with bacterial growth was low and yielded as many skin contaminants as cases of bacteremia. Our study highlights the need for further quality improvement efforts to reduce unnecessary blood cultures in routine SSTI cases.     

Clinafloxacin versus piperacillin-tazobactam in treatment of patients with severe skin and soft tissue infections

Patients (n = 409) with severe skin and soft tissue infections (SSTIs) were randomized to receive clinafloxacin or piperacillin-tazobactam (plus optional vancomycin for methicillin-resistant cocci), administered intravenously, with the option to switch to oral medication. Most patients had cellulitis, wound infections, or diabetic foot infections. Staphylococcus aureus, Enterococcus faecalis, and Pseudomonas aeruginosa were the most common baseline pathogens. Fewer baseline pathogens were resistant to clinafloxacin (1.8%) than to piperacillin-tazobactam (6.2%) (P = 0.001). The clinafloxacin and piperacillin-tazobactam groups did not differ significantly in clinical cure rates (68.8 and 65.2%, respectively) or microbiologic eradication rates (61.5 and 57.2%). Clinafloxacin yielded higher eradication rates for all three of the most common pathogenic species, although no differences were statistically significant. Within the power of this study, the overall frequency of adverse events was similar (P = 0.577) in the two treatment groups. Drug-associated adverse events (P = 0.050) and treatment discontinuations (P = 0.052) were marginally more frequent in the clinafloxacin group, primarily due to phototoxicity in outpatients receiving clinafloxacin. Although most cases of phototoxicity were mild to moderate, four cases were reported as severe. In summary, clinafloxacin monotherapy was equivalent in effectiveness to therapy with piperacillin-tazobactam plus optional vancomycin in the treatment of hospitalized patients with severe SSTIs.     

Amoxicillin combined with clavulanic acid for the treatment of soft tissue infections in children

We compared responses to amoxicillin combined with clavulanic acid (ACA) with a cefaclor regimen in children with skin and soft tissue infections (impetigo and cellulitis) due to Staphylococcus aureus, Streptococcus pyogenes, and Haemophilus species. All isolates from the 41 patients we were able to evaluate were susceptible to ACA by disk susceptibility testing at the onset of treatment. The 21 children receiving ACA and 18 (90%) of 20 taking cefaclor responded to therapy. Clinical cure was achieved in 18 (86%) of 21 and 18 (90%) of 20 in the two groups, respectively. Bacteriological failure occurred in 2 (10%) patients in the cefaclor group and none in the group receiving ACA; however, there were 2 (9%) relapses and 1 (5%) reinfection among the 21 children taking ACA. Adverse effects, although mild, occurred more commonly (9 of 21 versus 1 of 20; P = 0.005) with ACA than with cefaclor.     

Treatment of bone and soft tissue infections with teicoplanin

The use of teicoplanin was evaluated in a group of 33 patients, which included 18 prosthetic infections, seven with osteomyelitis, five skin and soft tissue infections, and three cases of septic arthritis. The bacterial pathogens isolated were 27 isolates of Staphylococcus aureus (methicillin sensitive 18; methicillin resistant 9), Staph. hominis (2), Staph. epidermidis (1), Staph. haemolyticus (2), Enterococcus faecalis (1), Streptococcus pyogenes (1), Peptococcus spp. (1). Eleven patients had polymicrobial infections (Gram-positive plus Gram-negative and/or anaerobic bacteria). In ten cases (nine polymicrobial infections) teicoplanin was used in combination with other antibiotics. Teicoplanin was administered intravenously 400 mg every 24 h in 26 cases, 200 mg every 24 h in six cases and 600 mg every 24 h in one case. The duration of the treatment ranged from 9 to 73 days with a mean of 27.3. Efficacy was evaluable in 30 patients, because in three patients treatment was stopped because of adverse reactions. Cure or improvement was noted in 28 patients (93%). Bacteriological cure occurred in 25 patients (83.3%).     

Efficacy and safety of intravenous daptomycin in Japanese patients with skin and soft tissue infections

Daptomycin is a lipopeptide antibiotic active against gram-positive organisms and recently approved for marketing in Japan. This study investigates the efficacy and safety of daptomycin in Japanese patients with skin and soft tissue infections (SSTIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) for regulatory filing in Japan. Overall, 111 Japanese patients with SSTI were randomized in this open-label, randomized, active-comparator controlled, parallel-group, multicenter, phase III study. Patients received intravenous daptomycin 4 mg/kg once daily or vancomycin 1 g twice daily for 7–14 days. Efficacy was determined by a blinded Efficacy Adjudication Committee. Among patients with SSTIs caused by MRSA, 81.8 % (95 % CI, 69.1–90.9) of daptomycin recipients and 84.2 % (95 % CI, 60.4–96.6) of vancomycin recipients achieved a successful clinical response at the test-of-cure (TOC) visit. The microbiological success rate against MRSA at the TOC visit was 56.4 % (95 % CI, 42.3–69.7) with daptomycin and 47.4 % (95 % CI, 24.4–71.1) with vancomycin. Daptomycin was generally well tolerated; most adverse events were of mild to moderate severity. The measurement of daptomycin concentration in plasma revealed that patients with mild or moderate impaired renal function showed similar pharmacokinetics profiles to patients with normal renal function. Clinical and microbiological responses, stratified by baseline MRSA susceptibility, suggested that patients infected with MRSA of higher daptomycin MIC showed a trend of lower clinical success with a P value of 0.052 by Cochran–Armitage test. Daptomycin was clinically and microbiologically effective for the treatment of MRSA-associated SSTIs in Japanese patients.     

儿童浅表组织肿块超声诊断的分析研究

目的探讨儿童浅表组织肿块的超声图像特征,以提出诊断思路。方法回顾性分析经病理确诊的101例(101个肿块)儿童浅表组织肿块的超声图像特征。结果儿童浅表软组织肿块以良性常见(98/101,97.03%),其中囊性肿块占43.88%(43/98),实性肿块占56.12%(55/98)。囊性肿块以表皮样囊肿、血肿多见(58.14%,25/43),实性肿块以脂肪瘤、血管瘤常见(41.81%,23/55)。恶性浅表组织肿块3例,呈浸润性生长,无完整包膜,内部回声不均,瘤体内测及血流信号,动脉血流阻力指数多为高阻力改变。结论超声医师在诊断儿童浅表组织肿块时,根据超声图像特征,结合临床资料,能够对大多数病变作出正确诊断,为临床治疗提供可靠的图像依据。     

Comparison of bedside ultrasound and panorex radiography in the diagnosis of a dental abscess in the ED

Objective

The purpose of the study was to compare bedside ultrasound (US) and panorex radiography in the diagnosis of a dental abscess in emergency department (ED).

Methods

A retrospective review of ED records of adult patients with atraumatic facial pain, swelling, and toothache who received a panorex x-ray and bedside US was performed. Medical records were reviewed for ED evaluation and disposition. Sensitivity and specificity of US and panorex x-ray were calculated to determine the clinical utility of the 2 tests.

Results

A total of 19 patients were identified. No periapical abscess was reported on panorex x-rays in 7 (37%) of 19 patients. Ultrasound agreed with panorex x-rays in 6 (86%) of 7 cases. One case where US disagreed with x-rays was evaluated by dentistry consultants; and incision and drainage were performed, confirming the presence of an abscess. An x-ray diagnosis of periapical abscess was made in 12 (63%) of 19 patients. Ultrasound agreed with panorex x-ray in 10 (83%) of 12 cases. In 1 of the 2 cases where US disagreed with panorex x-rays, x-ray abnormalities were reported on the nonsymptomatic side. The other patient was given antibiotics and recommended outpatient follow-up. Follow-up information was not available to further confirm the presence of an abscess. Assuming that the patient who was lost to follow-up had dental abscess, the sensitivity and specificity of US in diagnosing a dental abscess were 92% and 100%, respectively.

Conclusions

Bedside US is nonionizing, is readily available, and can provide an alternative to panorex x-rays in the evaluation of a dental abscess in ED.     

急诊科医生主导的床旁超声技术在创伤救治中的作用

目的 探讨急诊医生主导的床旁超声技术在多发创伤中的作用.方法 119例创伤患者分为急诊超声组(A组)和对照组(B组),A组63例由急诊科医生进行创伤超声重点评估,B组56例由超声科医生进行床旁常规超声检查,比较两组超声检查的准确率,并记录完成超声检查距入院的时间,A组中的42例患者在超声引导下进行颈内静脉穿刺,B组中的39例患者采用常规体表定位法进行颈内静脉穿刺,比较两组的一次进针成功率、总成功率、并发症发生率、穿刺时间等.结果 与B组比较,A组能在入院后更短的时间内完成超声检查(P＜0.01),两组的超声检查准确率均为100%,A组在超声引导下进行颈内静脉穿刺的一次进针成功率、总成功率明显高于B组(P＜0.05),而并发症发生率、穿刺所用时间明显少于B组(P＜0.05).结论 急诊科医生主导进行的急诊床旁超声技术,在创伤病情评估、中心静脉穿刺等方面有巨大的优势,有助于创伤患者的救治,应该在急诊科推广应用.     

高频彩色多普勒超声对肌肉软组织病变的诊断价值

目的探讨高频彩色多普勒超声在肌肉软组织病变诊断中的应用价值。方法应用高频彩色多普勒超声对36例肌肉软组织病变患者进行检查,分析病变的回声特点、大小、范围、边界、包膜、结构等,部分患者检查结果与X线、CT、MRI等结果对照分析。结果高频彩色多普勒对36例患者肌肉软组织病变患者的检查具有较高的灵敏度,肌腱断裂、肌肉损伤、肌肉肿瘤及炎性病变等在声像图上有特异性表现。结论高频彩色多普勒能清晰显示肌肉软组织病变的物理性质,对软组织病变有较高的诊断灵敏度和特异度,有较高的临床应用价值。