床旁B超在英国急诊医学中的应用

急诊患者床旁B超检查是近年来急诊医学发展中的一个新的“特点”，对于某些特殊急诊患者，例如创伤患者，急诊医师自己在床旁进行有针对性的B超检查，的确有助医师对于患者的确诊大有帮助。这在美英等两方发达国家床旁B超已是急诊医师所必须掌握的技术之一，目前，有在全球广泛发展的趋势，张茂等在急诊ICU率先开展应用B超诊断危重患者气胸的临床研究，并认为其具有较高的临床价值。我们有机会到英国伦敦皇家医学院附属医院急诊科从事临床和研究工作一年，对英国急诊医学有较多的了解和认识，在英国急诊临床工作中，其中许多独特的“亮点”，对于我国的急诊医学的发展有借鉴和帮助，在此，特别想就英国急诊科床旁B超的应用及其特点做一介绍，供同仁参考，     

透视定位在软组织异物取出术中的应用

软组织异物的治疗中的准确定位一直是广大临床医师较为棘手的问题。作者自1984年8月-2004年5月共收治软组织异物病人472例，取出各种异物944枚，均在透视下，局麻小切口、用一把血管钳直接行异物取出。具有损伤小，耗时短，操作方便之优点。现将具体操作及体会报告如下：     

B超在眼内异物诊断及定位中的应用价值

眼内异物是特殊而严重的眼外伤,早期的诊断,及早取出异物极为重要,而异物的定位对手术成功与否具有重要意义.影象学定位是诊断眼内异物及手术摘出的重要依据,包括X线、CT、超声及MRI等.本文着重分析B超对眼内异物诊断及定位的优势.     

B型超声在四肢躯干软组织异物中的应用（附48例报告）

四肢及躯干软组织异物,为临床常见创伤。较表浅的可在直视下取出,部分病人可由体征定位。对于金属异物则往往通过X线定位。但对非金属异物的定位X线亦无能为力。我院B超室自1993年—1999年对48例外伤可疑异物残留的病人行超声检查,并经手术证实,正确率94％。报告如下:     

急诊B超在眼球异物诊断的应用

B超检查具有普及、简便的特点,除广泛应用于临床各科的一般检查之外,在急诊领域也日益受到重视,并发挥着重要的作用,作者自1990年2月以来将B超检查用于眼科急诊,在检出眼球异物方面取得较好效果,现报道如下。 资料与方法 1.临床资料 患者共20例,年龄2岁-42岁,男性15例,女性5例。临床以眼部外伤入院,致伤原因依次为爆炸、使用工具意外、汽枪枪击等,经眼科检查疑眼球异物共26只眼,临床表现为角膜穿孔、巩膜穿孔、前房积血、晶体混浊、眼球塌陷以及视力障碍等。 2.检查方法     

急诊床旁B超诊断肝癌破裂1例

患者男 ,75岁。无诱因右上腹疼痛 9h入院。患者呈急性病容 ,大汗淋漓。自觉右上腹胀痛 ,向右肩及右腰部放射。伴恶心 ,呕吐少量胃内容物 1次。既往曾因“肠穿孔”行肠部分切除 ,肠端 -端吻合术 ,无其他病史。急诊床旁B超检查示 :右叶膈面下局部包膜略向外突起且不完整 ,该部位肝实质内探及一大小约 3 .8cm× 3 .6cm× 3 .2cm之实质等回声包块 ,靠膈面一侧边界不清 ,边缘不规整 ,其外侧有絮状回声 ,其余部分边界清楚 ,周边有低回声晕。肝周、肝肾间、脾周、脾肾间、肠间多处、双侧髂窝均探及大小不等的不规则液性暗区 ,最深处 6.7cm。B超提…     

B超在眼内异物诊断中的应用

1 一般资料 本组35例中.男23例,女12例;年龄2～59岁:受伤时间最短1天,最长19年。异物位置:虹膜3例,晶体5例,睫状体及前部玻璃体7例,后玻璃体11例,视网膜及球壁4例,眼壁5例。异物大小:最小者0.2×0.2×0.2cm,最大5×3×3mm。眼内1枚异物28例,2枚异物3例,多枚异物4例。 2 仪器和方法 仪器:APOGEE CX。方法:一般采用眼睑外直接     

急诊B超检查在急腹症中的应用价值

目的探讨急诊B超检查在急腹症中的应用价值。方法E505例急腹症患者作急诊B超检查，并将结果与临床最后诊断相对照分析。结果505例受检患者，外伤组202例，检出胸腹腔脏器损伤出血共21例，检出率100％，腹腔脏器损伤定位符合率71．8％，非外伤组303例，检出与急腹症相关疾病共154例，检出率87．5％。结论急诊B超检查在外科与妇产科急腹症中具有较高的检出率与诊断符合率。     

B超在腹部创伤急诊中的诊断价值

我院从1994年4月至2001年3月开展急诊超声,旨在提高B超在腹部创伤急诊中的应用及诊断价值,现回顾如下。     

Migrating Sternal Rod: Ultrasound Identification of an Unusual Soft Tissue Foreign Body

Background

Sternal hardware migration from its original site of implantation is a rare entity. Bedside ultrasound may identify migrated hardware if the site of migration is the subcutaneous tissue.

Objectives

This case report will discuss the unusual phenomenon of migrating sternal hardware, as well as the ultrasonographic characteristics of soft tissue foreign bodies.

Case Report

A 51-year-old man presented to the Emergency Department with a 2-month history of intermittent lower abdominal pain, 11 months status post bilateral lung transplant surgery. His examination was remarkable for a palpable mass over the left lower quadrant of the abdomen. Initial bedside ultrasound identified a soft tissue foreign body in the subcutaneous tissue overlying the left lower quadrant of the abdomen. Further evaluation using plain radiography and computed tomography ultimately diagnosed the foreign body as a metal rod, which had migrated from his sternum. The sternal rod was removed at the bedside, and he was discharged the next day without any complications.

Conclusion

Sternal hardware migration is uncommon, but in patients who have undergone surgery involving sternal fixation, this diagnosis should be considered as a cause for unusual symptoms.     

A Survey of Bedside Ultrasound Use by Emergency Physicians in California

Objective. The purpose of this study was to investigate the current practice of emergency physician–performed bedside ultrasound examinations in California and to assess differences between academic and community practice. Methods. We queried all emergency departments (EDs) in California to determine whether bedside ultrasound was used by emergency physicians. Among EDs that were using bedside ultrasound, we administered a survey to assess use patterns, credentialing criteria, and quality assurance (QA) programs. Results. We contacted all eligible EDs (n = 293) by telephone and had a 100% response rate for our primary question: 101 EDs (34%) reported use of bedside ultrasound. Of these 101 EDs, 97 (96%) responded to the secondary survey, showing the following: (1) 48% of physicians at each site were credentialed to use ultrasound in at least 1 modality; (2) 70% of EDs used American College of Emergency Physicians (ACEP) criteria for credentialing guidelines; and (3) 33% had an ultrasound QA program. Comparing practice settings, 68% of academic departments used bedside ultrasound compared with 29% of community departments (difference, 39%; 95% confidence interval [CI], 23% to 54%; P < .0001). In academic departments, a mean of 60% of physicians were credentialed, compared with 41% in community EDs (difference, 19%; 95% CI, 2.5% to 35%; P = .036). Conclusions. Most California EDs do not use bedside ultrasound. Although most EDs using ultrasound report that they follow ACEP emergency ultrasound guidelines, most do not have a QA program as recommended by these guidelines. Compared with community EDs, academic EDs are more likely to use bedside ultrasound, have physicians credentialed in ultrasound use, and have QA programs.     

Point-of-Care Ultrasound is Associated With Decreased Length of Stay in Children Presenting to the Emergency Department With Soft Tissue Infection

Background

Point-of-care ultrasound (POCUS) is increasingly being used to differentiate cellulitis from abscess in the pediatric emergency department (ED). POCUS has also been shown to decrease length of stay (LOS) for other applications among adult patients.

ABSCESS: Applied Bedside Sonography for Convenient Evaluation of Superficial Soft Tissue Infections

Objectives: Soft tissue infections are a common presenting complaint in the emergency department (ED). The authors sought to determine the utility of ED bedside ultrasonography (US) in detecting subcutaneous abscesses. Methods: Between August 2003 and November 2004, a prospective, convenience sample of adult patients with a chief complaint suggestive of cellulitis and/or abscess was enrolled. US was performed by attending physicians or residents who had attended a 30‐minute training session in soft tissue US. The treating physician recorded a yes/no assessment of whether he or she believed an abscess was present before and after the US examination. Incision and drainage (I + D) was the criterion standard when performed, while resolution on seven‐day follow‐up was the criterion standard when I + D was not performed. Results: Sixty‐four of 107 patients had I + D–proven abscess, 17 of 107 had negative I + D, and 26 of 107 improved with antibiotic therapy alone. The sensitivity of clinical examination for abscesses was 86% (95% confidence interval [CI] = 76% to 93%), and the specificity was 70% (95% CI = 55% to 82%). The positive predictive value was 81% (95% CI = 70% to 90%), and the negative predictive value was 77% (95% CI = 62% to 88%). The sensitivity of US for abscess was 98% (95% CI = 93% to 100%), and the specificity was 88% (95% CI = 76% to 96%). The positive predictive value was 93% (95% CI = 84% to 97%), and the negative predictive value was 97% (95% CI = 88% to 100%). Of 18 cases in which US disagreed with the clinical examination, US was correct in 17 (94% of cases with disagreement, χ²= 14.2, p = 0.0002). Conclusions: ED bedside US improves accuracy in detection of superficial abscesses.     

Point of Care Ultrasound Use by Associate Providers for Differentiating Abscess Versus Cellulitis Skin and Soft Tissue Infection in the Emergency Department

BackgroundSkin and soft tissue infections (SSTIs) are a common complaint in the ambulatory setting and pose a significant burden on the health care system.ObjectivesWe sought to determine the accuracy of ultrasound for detecting soft tissue abscesses by emergency medicine associate providers (APs).MethodsThis was a prospective observational study of adult patients with suspected SSTI in the emergency department of a rural tertiary care academic medical center. The AP performed and interpreted point-of-care ultrasound (POCUS) of the suspected infected area. Ultrasound images and interpretation were reviewed by the attending emergency physician with either rejection or agreement of the image interpretation, diagnosis, and management. If incision and drainage was performed, presence or absence of purulent drainage was recorded.ResultsSixty-four patients with suspected SSTI were enrolled: 29 had POCUS-proven abscesses and 33 had cellulitis; 2 were excluded. AP clinical evaluation alone for identifying abscess revealed sensitivity of 92.3 (74.9–99.1), specificity of 67.7 (49.5–82.6), positive predictive value of 68.6 (57.0–78.2), and negative predictive value of 92.0 (81.4–100). The use of POCUS by APs in addition to clinical examination demonstrated sensitivity of 96.2 (80.4–99.9), specificity of 93.9 (79.8–99.3), positive predictive value of 92.6 (76.5–98.0), and negative predictive value of 96.9 (81.9–99.5). p values were <0.05 for test characteristics. Ultrasound results changed SSTI management decisions in 10 of 62 (16.1%) patients, with the most common change being a new incision and drainage or needle aspiration. Agreement of the POCUS interpretation between APs and attending physicians was 96.8% with a κ of 0.94 (0.85–1.00).ConclusionWith modest training, APs can successfully use POCUS to identify abscesses in patients in the emergency department with SSTIs. POCUS increases the ability to rule in the diagnosis and changes management in a clinically relevant number of patients with SSTIs.     

High‐Resolution Sonography Is Effective in Detection of Soft Tissue Foreign Bodies

Objective. Patients with penetrating trauma or field injuries are commonly encountered by emergency physicians. Clinical examination by inspection or palpation can detect superficial foreign bodies (FBs), and radiographs can detect radiopaque FBs. However, soft tissue FBs can be easily missed. The aim of our series was to evaluate the role of high‐resolution sonography in detection of soft tissue FBs. Methods. All patients referred to our center for sonographic evaluation of suspected soft tissue FBs from 1999 to 2008 were included in this analysis. Patients were scanned with an ultrasound machine using a 7.5‐MHz transducer. The suspected area was scanned in both axial and sagittal planes. The nature of the FB, length, and depth from the surface were recorded and reported. The presence of an FB was confirmed by surgical excision. Results. During the study period, 123 patients underwent sonography for a suspected FB, of which 12 were lost to follow‐up and excluded from the analysis. The study group included 73.8% male patients; the mean age was 36.2 years. Wood fragments and wooden thorns were the most frequently observed FBs, at 46.2% and 36.2%, respectively. The surgeon was satisfied with the reported depth of the FB from the surface in most cases (89%). The overall sensitivity and specificity of sonography were 94.5% and 53.8%. Conclusions. High‐resolution sonography is a very sensitive tool in diagnosis of soft tissue FBs. It also helps the surgeon with accurate localization, permitting easy removal.     

急诊无痛胃镜诊疗特殊人群上消化道异物110例临床分析

目的:总结特殊人群上消化道异物行急诊无痛胃镜诊断与治疗的体会。方法:回顾性分析2004年11月至2014年11月收治的行急诊无痛胃镜的上消化道异物特殊人群110例的临床资料。结果 :顺利取出上消化道异物107例,胃镜治疗前、过程中及治疗后的血压、心率、呼吸平稳。结论:对特殊人群的上消化道异物行急诊无痛胃镜的治疗成功率高,安全性好。     

超声影像及彩色多普勒血流显像技术在骨及软组织血管瘤诊断中的价值

作者论述了应用超声影像和彩色多普勒血流显像技术诊断骨及软织织血管瘤的特征，通过57例血管瘤的超声影像与手术、病理、放射影像的对比分析，证实了超声影像检查是术前诊断血管瘤最可靠的检查方法。其中9例骨血管瘤显示不同程度的骨质破坏和实性低回声肿物；48例软组织血管瘤可见迂曲扩张的管状结构互相交通、挤压血管瘤时可见其内充盈彩色血流信号。     

贲门癌患者术前胃内注水B超的临床价值

术前判断贲门癌能否被切除较为困难，为了寻找术前判断的较好方法，作者对６７例贲门癌患者进行了对比研究，将所有病例随机分为两组，分别进行胃内注水后Ｂ超检查及常规检查，然后与手术结果比较，发现胃内注水Ｂ超组的手术符合率为８３．３％。对照组为６４．５％。