soft tissue ultrasound - uk healthcare cecentral tissue cf 2013.pdf · 50%!!! • ultrasound...
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Matt Dawson MD, RDMS, RDCS University of Kentucky Director of Emergency Ultrasound
MESA Director of Ultrasound
Soft Tissue Ultrasound
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Case
• 63 y/o Male presents with redness, pain and swelling to his Leg.
• Cellulitis......abscess?
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What do you do?
• Incise?
• Antibiotics and home?
• CT?
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Ultrasound
AntibioticsDrainOR
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Necrotizing Fasciitis
Send to OR
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What Just Happened?• Cellulitis: You saved the patient a painful
procedure
• CT: resources/radiation
• Abscess: You prevented an ineffective treatment (antibiotics alone)
• Nec Fasc: You may have saved their LIFE!
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Not Me!• “I’ve been doing this for years without
ultrasound......”
Dr. Oz
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50%!!!• Ultrasound changed the management of patients
with cellulitis in 71/126 (56%) of cases.• Tayal VS, Hasan N, Norton HJ, Tomaszewski CA.
The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med. 2006;13(4):384-8.
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Soft Tissue Infections: Why ultrasound?
• Physical exam alone can be misleading
• May prevent unnecessary painful procedures
• Prevents ineffective treatment
• Helps localize and direct drainage procedures
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Goal of exam
• Identify one of the following three findings:
• Abscess
• Cellulitis
• Normal Skin
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Probe Selection
• Linear Probe
• High Frequency
• Advantage: Excellent image resolution
• Disadvantage: Shallow imaging only
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Scanning Technique• Scan in two planes
• Adjust depth: view in both far and shallow fields
• Use doppler to ID surrounding vascular structures
• Consider water baths
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Scanning in two planes
• Image is 2D
• Abscess is 3D
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Water Baths
• Water is an excellent conductor of sound
• Probe is sealed
• Non painful exam
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Other Option
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Water Bath
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Normal Skin
• Skin
• Subcutaneous fat
• Fascia
• Muscle
• Vascular structures
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Cellulitis• Cobble Stoning
• Increased echogenicity of the subcutaneous tissue
• Fluid and infection between lobules in the subcutaneous tissue
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Cellulitis• Cobble Stoning
• Increased echogenicity of the subcutaneous tissue
• Fluid and infection between lobules in the subcutaneous tissue
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Cellulitis• Cobble Stoning
• Increased echogenicity of the subcutaneous tissue
• Fluid and infection between lobules in the subcutaneous tissue
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Skin Abscess• Abscess cavity with
surrounding cobblestoning
• Typically spherical
• Abscess is anechoic or mixed echos with debris
• Pressure induces movement of purulent material
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Skin Abscess• Abscess cavity with
surrounding cobblestoning
• Typically spherical
• Abscess is anechoic or mixed echos with debris
• Pressure induces movement of purulent material
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Management
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Foreign Body Localization
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Foreign Body Localization
• Challenging
• Hand and foot most commonly affected, high risk of iatrogenic injury from blind exploration
• Ultrasound can guide removal in real time
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Disclaimer
• NOT EASY!
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But....• It’s the best we have
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WoodUltrasound is more sensitive than CT for wood Foreign Body
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Metal and GlassMetal and glass usually radio-opaque
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Organic Matter and PlasticOrganic matter and plastic are radiolucent: Does not show up on x-rays
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Foreign Bodies• Most common
radiolucent foreign body is wood (hand and foot)
• Anatomy can be confusing, scan the contralateral extremity
• Most radiolucent foreign bodies are superficial (<2cm)
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Foreign Bodies• Most common
radiolucent foreign body is wood (hand and foot)
• Anatomy can be confusing, scan the contralateral extremity
• Most radiolucent foreign bodies are superficial (<2cm)
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Foreign Bodies• Most common
radiolucent foreign body is wood (hand and foot)
• Anatomy can be confusing, scan the contralateral extremity
• Most radiolucent foreign bodies are superficial (<2cm)
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• FB Examples
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• FB Examples
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• FB Examples
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• FB Examples
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• FB Examples
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• FB Examples
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Things to watch out for
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Lymph Nodes
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Reactive Lymph Nodes
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Reactive Lymph Nodes
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Reactive Lymph Nodes
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Reactive Lymph Nodes
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• Pseudoaneurysm
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• Pseudoaneurysm
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• Never mismanage a cellulitis/abscess again!
• Quit guessing and sleep well after your decision about the “red leg”.
Summary
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