REBEL Core Cast 54.0 Wound Care I – Foreign Bodies

Apr 21, 21
REBEL Core Cast 54.0 Wound Care I – Foreign Bodies

Take Home Points

  • FBs are a very common complication of wounds.
  • X-ray is poor at detecting foreign bodies
  • US is a tremendous tool and be used dynamically at the bedside to assist w FB extraction
  • Prophylactic antibiotics are not routinely recommended

REBEL Core Cast 54.0 – Wound Care I – Foreign Bodies

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How common are Foreign Bodies?

  • 11 million patients present to the ED with traumatic wounds every year
  • Approximately one patient every 3 seconds
  • 1 in 7 wounds (7-15%) may contain foreign bodies
  • We miss 1/3rd (38%) foreign bodies on initial evaluation.

What Complications arise from foreign bodies?

Delays in treatment or missed foreign body may lead to:

  • infection
  • delayed wound healing
  • inflammation
  • loss of function

Missed FB is a common reason for malpractice claims secondary to complications in wound care management.

  • The payouts are small
  • But the impact is significant due to large number of patients
  • Claims due to wound care complications netted 3% to 11% of all dollars paid out

How do we evaluate wounds for foreign bodies?

A detailed history and thorough physical exam are vital

  • Typically our patients can reliably tell the mechanism and type of foreign body
  • Altered patients may be unable to provide Information
  • These situations can provide a diagnostic dilemma

HPI: Obtain Information:

  • Type of foreign body
  • Mechanism of injury
  • Tetanus
  • Past medical history: assessment of high-risk individuals requiring antibiotics

Physical exam:

  • Note range of motion, 
  • Tendon function
  • Signs of infection
  • Neurovascular exam: sensation, pulses, cap refill
  • Palpable foreign body
  • Skin discoloration

Considerations for Imaging:

  • Inability to completely visualize the depth of wound
  • Deep wounds caused by glass
  • Patient believes there is a foreign body
  • Small, thin, breakable, or brittle object
  • Object easily be buried beneath the skin
  • Severe wound pain
  • Painful mass
  • Discoloration under the skin
  • Missing portion of the object
  • Penetration through rubber sole

How good are X-rays for assessing foreign bodies?

X-ray: 

  • Poor sensitivity 
  • Inexpensive and low radiation
  • It can also help identify other injuries
  • Cadaver study: 160 foreign bodies (fresh wood, dry wood, glass, porcelain and plastic fragments) implanted in cadaver feet and subsequently imaged with different modalities
  • Overall sensitivity and specificity for foreign body detection was 29% and 100% for radiographs,
  • Glass alone sensitivity was 53%

Is CT better than Xray?

  • Overall sensitivity and specificity foreign body detection is 63% and 98% for CT
  • Glass alone sensitivity was 100%
  • CT is a good choice if you know what the foreign body will show up (glass of metal)

When should you order a CT scan?

  • CT scan should be considered the type of foreign body is known.
  • If the foreign body is compressing a neurovascular structure
  • CT imaging in retained foreign bodies from older injuries may show additional Information like infection and abscess, which can change/guide management

Is there a role for Ultrasound in the detection of foreign bodies?

  • With trained provider, ultrasound sensitivity for the localization of foreign bodies can reach 96.7% – 100%
  • US is that its a dynamic imaging modality
  • Can use it at the bedside to help guide our extraction

Which foreign bodies need specialty consultation?

  • Significantly deep structures
  • Failed retrieval requiring further dissection
  • Neurovascular compromise
  • Objects located near vascular structures
  • Concerns for compartment syndrome

Which patients with FBs need antibiotics?

  • Heavily contaminated puncture wounds 
  • Patients with: Diabetes mellitus, Immunodeficiency, 
  • Retained organic foreign body
  • Injuries through an intact shoe
  • Follow wounds closely for evidence of infection regardless of the decision to treat with antibiotics

Take-Home Points:

  • FBs are a very common complication of wounds.
  • X-ray is poor at detecting foreign bodies
  • US is a tremendous tool and be used dynamically at the bedside to assist w FB extraction
  • Prophylactic antibiotics are not routinely recommended

Read More

REFERENCES:

  1. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. National Center for Health Statistics. [Link is HERE]
  2. Davis J et al. Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis. Acad Emerg Med. 2015. PMID: 26111545
  3. Pfaff JA, Moore GP. Reducing risk in emergency department wound management. Emerg Med Clin North Am. 2007. PMID: 17400081
  4. Pattamapaspong N. et al. Accuracy of radiography, computed tomography and magnetic resonance imaging in diagnosing foreign bodies in the foot. Radiol Med. 2013. PMID: 22744349
  5. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995. PMID: 7605521
  6. Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am. 2008. PMID: 18295686
  7. Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med. 2008. PMID: 18768947
  8. Rubin Get al. Nail puncture wound through a rubber-soled shoe: a retrospective study of 96 adult patients. J Foot Ankle Surg. 2010. PMID: 20797584
  9. Ellsworth Wright MD & Brandon Somwaru DO, “POCUS and Soft Tissue Foreign Bodies”, REBEL EM blog, January 18, 2021. [Link is HERE]
  10. Lyon M et al.
  11. Detection of soft tissue foreign bodies in the presence of soft tissue gas. J Ultrasound Med. 2004. PMID: 15154535

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post REBEL Core Cast 54.0 Wound Care I – Foreign Bodies appeared first on REBEL EM - Emergency Medicine Blog.

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