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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

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.

Databases, Google Scholar, Cochrane collaboration and bibliographies searched and researchers contacted by personal email.

Search Outcome

5 significant research papers found
9 Case reports identified

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Schlager D et al. 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
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
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)
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
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)
BudhramGR, 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
Ginsberg et al. 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
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
Lee et al. 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
Lewis et al 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.
McLaughlin et al 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
Paziana et al 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
Perera et al 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

Comment(s)

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.

Clinical Bottom Line

After limited dedicated teaching, ED physician ultrasound for foreign body detection approaches sufficient sensitivity to be considered clinically useful

References

1. Schlager D, Sanders AB, Wiggins D, Boren W. Ultrasound for the detection of foreign bodies. Annals of Emergency Medicine 1991;20(2):189-191.
2. Crystal CS et al. Bedside ultrasound for the detection of soft tissue foreign bodies: A cadaveric study. Journal of Emergency Medicine 2009;36(4):377-380
3. Hill R, Conron R, Greissinger P, Heller M. Ultrasound for the detection of foreign bodies in human tissue Annals of Emergency Medicine 1997;29(3):353-356
4. Orlinsky M, Knittel P, Feit T, Chan L, Mandavia D The comparative accuracy of radiolucent foreign body detection using ultrasonography American Journal of Emergency Medicine 2000;18:401-403
5. Nienaber A, Harvey M, Cave G. Accuracy of bedside ultrasound for the detection of soft tissue foreign bodies by emergency doctors Emergency Medicine Australasia 2010;22:30-34.
6. Budhram GR, Schmunk JC. Bedside ultrasound aids identification and removal of cutaneous foreign bodies: A case series Journal of Emergency Medicine 2014;47(2);43-48
7. Ginsberg MJ, EllisGL, Flom LL, Detection of soft-tissue foreign bodies by plain radiography, xerography, computed tomography and ultrasonography. Annals of Emergency Medicine 1990;19(6):701-703
8. Graham DD. Ultrasound in the Emergency Department: Detection of wooden foreign bodies in the soft tissues The Journal of Emergency Medicine 2002;22(1):75-79
9. Lee GPC, Chung KL, Kam CW. Ultrasound-guided foreign body removal Hong Kong Journal of Emergency Medicine 2008;15(2):106-110
10. Lewis D, Jivraj A, Atkinson P, Jarman R My patient is injured: identifying foriegn bodies with ultrasound Ultrasound 2015;23(3):174-180
11. McLaughlin R, Collum N, McGovern S, Martyn C, Bowra J. Emergency department ultrasound (EDU): clinical adjunct or plaything? Emergency Medicine Journal 2005;22:333-335
12. Paziana K, Fields JM, Rotte M, Au A, Ku B Soft tissue foreign body removal technique using portable ultrasonography Wilderness and Environmental Medicine 2012;23:343-348
13. Perera P, Mandavia D Emergency Ultrasound Emergency Medicine 2008;40(4):25-26
14. Testa A, Giannuzzi R, Zirio G, La Greca A, Gentilioni Silveri N. Ultrasound detection of foreign body and gas contamination of a penetrating wound Journal of Ultrasound 2009;12(1):38-40