A 53-year-old homeless alcoholic female presented to the emergency department with a chief complaint of localized left lower quadrant abdominal pain secondary to a possible gunshot wound. She was unclear but stated she thinks some boys in a gang fired at her two days prior with a possible BB gun. Pertinent medical history included psychiatric history, morbid obesity (BMI>40), chronic alcohol abuse, sepsis and hypoxemic respiratory failure. The patient was clinically intoxicated upon arrival and therefore history was of limited accuracy.
Upon arrival, patient appeared stable and vitals were as follows:
BP: 121/63 | HR: 73 | RR: 18 | T: 98.4 | Sp02: 98% on RA
Physical examination revealed a 10x10 cm area of ecchymosis with a central penetrating wound about 2mm, to the left lower quadrant. The patient was tender to palpation around the affected area but there was no significant warmth or erythema to suggest infection. No palpable foreign bodies were identified. There were no signs of peritonitis: the remainder of the abdominal examination was benign and patient had active bowel sounds. She denied vomiting, hematuria, hematochezia, and melena. She also denied shortness of breath, chest pain, and back pain.
To evaluate the wound for the presence of foreign bodies and for depth of penetration, bedside ultrasound was obtained. What do you see, and how would this change your patient management?
Figure 1: Wound prior to foreign body exploration.
Figure 2: A hyperechoic object with reverberation artifacts and shadow seen at 1cm.
Figure 3: Removal of FB under US guidance using curved hemostats.
Figure 4: Extracted pellet.
Answer and Learning Points
Answer:
In these scans, an echogenic foreign body can be observed 1 cm below the epidermis with associated reverberation and mirror artifact. Using ultrasound guidance, a curved hemostat was used to remove the foreign body after local anesthetic injection. Upon contact with the forceps, the foreign body can be seen fluctuating in position. A rounded edge on the foreign body can be seen on the image. Importantly, we clearly identified the peritoneal line to be > 4cm deeper than the foreign body and were able to safely determine the foreign body location to be significantly more superficial to the abdominal wall musculature.
Discussion
Soft tissue foreign bodies (FB’s) are a common reason for Emergency Department visits, with open wounds producing 4,171,000 visits to United States Emergency Departments in 2020 [1]. However, retained foreign bodies account for 7-15% of cases, particularly those involving the extremities. A granulomatous tissue response commonly known as an FB reaction results as the immune system attempts to isolate the FB from the host [2]. This can lead to serious adverse complications including soft tissue inflammation and infection. The most commonly retained FB materials are metal, glass and wood. Glass accounts for half of missed FB’s on physical examination and radiographs. Although essential, a physician-performed clinical history, physical examination, and wound exploration are not sufficient to exclude a FB from differentials [2]. Thus, imaging plays an essential role in improving patient outcomes that present with FB’s.
MRI is not a suitable imaging modality, as metallic contents may have hazardous movements due to the magnetic field. Computed tomography (CT) and ultrasound sonography (US) are the most effective imaging modalities. CT and US have similar sensitivity in identifying high-density objects such as stone, metal and glass [3]. Low-density foreign objects such as plastic and wood are remarkably difficult to see in techniques other than US, regardless of superficial or deep impaction. For example, radiographic images have a sensitivity of 7.4% for wood [3,4]. Sensitivity of ultrasound for FB is 80% on average, and it carries a specificity of 85%, with metals being much higher due to noticeable reverberation, and wood is more difficult to detect. However, the sensitivity of US to identify foreign bodies in soft tissues begins to decrease as the depth of the foreign body surpasses 4cm [4].
US provides a unique advantage to foreign body detection as it can provide instantaneous and simultaneous visualization of foreign bodies during extraction procedures with minimal risk and no exposure to radiation. In a study of pediatric patients presenting with an FB, sonography performed by EM physicians provided an overall sensitivity of 67% and a specificity of 96.6% [4]. US is inexpensive and provides real-time visualization, however the quality of US images is operator dependent [5].
|
Material of FB |
Ultrasound finding |
|
Stone |
Hyperechoic area with pronounced acoustic shadow |
|
Metal |
Hyperechoic area with reverberation artifacts |
|
Glass |
Hyperechoic area with comet tails; less visible than metal |
|
Plastic |
Hyperechoic area with slight acoustic shadow |
|
Wood |
Hypoechoic area with “halo” |
Table 1: A List of FB Materials and the Expected US Findings [3].
To perform this technique, scan use the linear probe in the area of the suspected location of the FB. The FB can be identified by characteristic reverberation or acoustic shadowing, with additional indications being signs of infection, edema, or interruption of the fascial planes. Position the probe so that the FB is visualized in the center of the screen, and mark this area with a surgical pen. Rotate the probe 90 degrees and ensure the FB is in the middle of the US screen. Then mark this area with a surgical pen. Where these markings cross should give you the exact location of the FB such that incision and probing with forceps will result in effective removal of the FB.
Removing foreign bodies is one of the least favorite procedures in the Emergency Department due to it’s difficulty and low success rates. Bedside ultrasound is easily performed and is a useful adjunct in the accurate identification of foreign bodies and also can provide real-time guidance in foreign body removal.
References
1) Cairns C, Kang K. National Hospital Ambulatory Medical Care Survey: 2020 emergency department summary tables. DOI: https://dx.doi.org/10.15620/cdc:121911.
2) Carneiro BC, Cruz IAN, Chemin RN, et al. Multimodality Imaging of Foreign Bodies: New Insights into Old Challenges. Radiographics. 2020;40(7):1965-1986. doi:10.1148/rg.2020200061
3) Haghnegahdar A, Shakibafard A, Khosravifard N. Comparison between Computed Tomography and Ultrasonography in Detecting Foreign Bodies Regarding Their Composition and Depth: An In Vitro Study. J Dent (Shiraz). 2016;17(3):177-184.
4) Davis J, Czerniski B, Au A, Adhikari S, Farrell I, Fields JM. Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis. Acad Emerg Med. 2015;22(7):777-787. doi:10.1111/acem.12714
5) Rupert J, Honeycutt JD, Odom MR. Foreign Bodies in the Skin: Evaluation and Management. Am Fam Physician. 2020;101(12):740-747.
This post was written by Cameron Olandt, Rachna Subramony, MD, Skyler Sloane, and Colleen Campbell, MD.