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

• REBEL EM: POCUS & Soft Tissue US

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