ACMT Visual Pearl: Watt – Ever is that Foreign Body?
Which type of foreign body should be suspected in a child who is drooling and has the following x-ray?
- Button battery
- Coin
- Magnet
- Marble
PEM POCUS Series: Soft Tissue Ultrasound
Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric soft tissue ultrasonography. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
Case Goals
- List the indications of performing a pediatric soft tissue point-of-care ultrasound (POCUS).
- Describe the technique for performing soft tissue POCUS.
- Interpret signs of cellulitis, abscess, and soft tissue foreign body on POCUS.
- Describe the limitations of soft tissue POCUS.
- Differentiate abscess from other soft tissue pathologies such as cysts and lymph nodes.
Case Introduction: Child with abdominal pain
Wendy is a 7-year-old girl who comes into the emergency department with redness, swelling, and pain on her left calf. Her symptoms started 1 week ago as a scratch which progressively got more red and painful. There has been no drainage from the lesion. She has had no fevers, but endorses elevated temperatures of 99 F.
On arrival, her vital signs are:
| Vital Sign | Finding |
|---|---|
| Temperature | 100.1 F |
| Heart Rate | 95 bpm |
| Blood Pressure | 105/68 |
| Respiratory Rate | 20 |
| Oxygen Saturation (room air) | 100% |
On her exam, you notice a 3 x 3 cm area of erythema and induration on her right calf with questionable fluctuance. The area is tender to palpation. She has no other skin findings noted, and she is able to bear weight. Given your concern for an abscess which may require drainage, a POCUS is performed.
Pediatric Soft Tissue POCUS
Figure 1. Linear ultrasound transducer
Probe
- Use a linear, high-frequency transducer.
Technique
- Hold the probe perpendicular to the skin.
- Scan the area of interest in 2 orthogonal (perpendicular) planes.
- If there is an abscess:
- Measure the abscess in 3 dimensions.
- Use color Doppler to ensure the structure is not vascular.
Pro Tips
- It is often helpful to ultrasound the unaffected side as a comparison.
- You cannot see what you didn’t scan. Scan the entirety of the affected area in 2 planes.
- Be aware of the patient’s comfort throughout the examination.
- A water bath may be helpful to visualize lesions in extremities such as the hands or feet.
- The probe sits just below the water’s surface and does not need to contact the skin.
- The benefits of using a water bath include better visualization of superficial structures and alleviates the need for direct skin contact.
Figure 2. Left: Water bath technique; Right: Ultrasound of a toe using a water bath (image courtesy of The Pocus Atlas and Moudi Hubeishy, MD)
Figure 3. Normal soft tissue layers on ultrasound (image courtesy of The Pocus Atlas)
Normally on a soft tissue ultrasound, you will see layers of defined structures separated by fascial planes.
- Epidermis/dermis: This is the topmost layer and has an hyperechoic appearance on ultrasound.
- Subcutaneous tissue: This deeper layer will appear slightly more hypoechoic.
- Muscular layer: This even deeper layer classically appears striated in the long axis view, while in the short axis view, it will have a speckled appearance.
- Bone: This layer appears hyperechoic cortex with posterior shadowing.
Cellulitis has a spectrum of appearances on ultrasound. Early cellulitis may present as skin thickening (Figure 4).
Figure 4. Cellulitis with skin thickening
As cellulitis progresses, there is effacement of the clearly differentiated structures seen above, and the tissue layers may appear hazy and hyperechoic. More advanced cellulitis may have “cobblestoning” which is the result of edematous fluid separating fat globules in the subcutaneous tissue.
Figure 5. Cellulitis with cobblestoning
Video 1. Ultrasound showing cellulitis with cobblestoning
Abscesses can have varied appearances. They can be anechoic (black) or filled with debris leading to a heterogeneous appearance of contents. The rim may be echogenic or blend in with surrounding tissue. They may be well-circumscribed or may have irregular borders.
 A. Abscess with irregular borders and heterogeneous appearance |  B. Well-circumscribed abscess with heterogeneous debris |  C. Larger abscess with well-circumscribed borders |
 D. Abscess with irregular borders and surrounding cellulitis |  E. Abscess with irregular borders and more homogenous appearance |  F. Superficial abscess with well-circumscribed borders |
Table 1. Examples of different appearances of abscesses on ultrasound
Video 2. Ultrasound of a cutaneous abscess
Color Doppler Flow
Placing color Doppler flow on a suspected abscess is helpful to differentiate it from a lymph node or blood vessel (see “Abscess Mimickers” section for lymph node examples). It may also aid in identifying nearby vasculature.
Figure 6. Abscess with color Doppler flow
Video 3. Ultrasound of cutaneous abscess with color Doppler flow
Posterior Acoustic Enhancement
Abscesses may exhibit posterior acoustic enhancement, which results in an enhanced transmission of ultrasound waves through a fluid-filled structure. Sometimes the abscess may not be as obvious and appear less anechoic due to debris. A squish (or swirl) sign may be elicited by putting pressure on the region, which will cause movement of the abscess contents. This finding has also been called “pus-talsis”.
Figure 7. Abscess with posterior acoustic enhancement
Video 4. Ultrasound of cutaneous abscess with squish sign
Size Measurement
Abscesses should be measured in 2 planes. Measure depth in 1 plane and length in 2. An easy way to remember this is to measure a plus sign (+) in one view, and a minus sign (-) in the other.
Figure 8. Measurement of abscess in two planes (images courtesy of Dr. Munaza Rizvi)
Lymph Nodes
Lymph nodes appear as ovid and well-circumscribed structures on ultrasound and may be confused for abscesses. They may be differentiated by their homogenous echotexture, central echogenic hilum. When inflamed, they may exhibit internal vascularity which should not be seen in an abscess.
Figure 9. A lymph node with a hilum (left) and a reactive inguinal lymph node with central vascularity (right)
Cysts
Cysts are fluid-filled, well-circumscribed structures which may be similar to abscesses. A common soft tissue cyst is an epidermoid cyst, which is a subepidermoid nodule filled with keratin. In addition to physical exam clues which may help distinguish cysts from abscess, cysts are typically very well-circumscribed and more homogenous in appearance.
Figure 10. Epidermoid cyst (image courtesy of The Pocus Atlas and Dr. Robert Jones)
Soft tissue foreign bodies are a common pediatric presentation and can be easily identified on ultrasound. X-rays can be used to identify foreign bodies; however, their use is limited to radiopaque objects. On ultrasound, foreign bodies often appear as a hyperechoic defect.
Figure 11. Hyperechoic foreign body (glass) embedded in the soft tissue of a foot with posterior shadowing
Video 5. Ultrasound of soft tissue foreign body
Foreign bodies embedded for a prolonged time may have signs of infection, such as cellulitis or abscess (Figure 12).
Figure 12. Wooden splinter embedded in a patient’s plantar foot with surrounding fluid collection consistent with abscess
A foreign body’s composition can affect how it appears on ultrasound. Different materials can produce characteristic ultrasound artifacts.
| Foreign Body | Ultrasound Findings | Ultrasound Image |
|---|---|---|
| Wood | Hyperechoic with posterior shadowing |  |
| Glass | Hyperechoic with posterior shadowing May have comet tail artifact |   Images courtesy of Dr. Ashkon Shaahinfar |
| Metal | Very hyperechoic Often has a comet tail or reverberation artifact |  Image courtesy of The Pocus Atlas and Robert Jones DO, FACEP |
Table 2. Foreign body characteristics on ultrasound
Foreign Body Removal
Ultrasound assistance in foreign body removal may be static (used to locate the foreign body’s position) or dynamic (using ultrasound to guide foreign body removal in real-time). Measuring the foreign body and assessing the object’s depth on ultrasound may assist in determining if bedside removal versus surgical removal is indicated.
Limited evidence suggests that there may be some sonographic differences between the papular urticaria of a “skeeter syndrome” and local cellulitis. On ultrasound, both findings will have thickening of dermal and subcutaneous tissues. Angioedema characteristically includes more linear, horizontal, striated bands — in comparison to cobblestoning found in cellulitis [1]. However, additional studies are needed to confirm this.
Figure 13. Ultrasound of angioedema (left) and cellulitis with cobblestoning (right). Angioedema image courtesy of Dr. Laura Malia.
Necrotizing fasciitis is a rare pediatric diagnosis but a rapidly progressive and life-threatening condition if not identified quickly. While necrotizing fasciitis is primarily a clinical diagnosis, imaging may be helpful when the diagnosis is uncertain. Computed tomography (CT) and magnetic resonance imaging (MRI) have good test characteristics; however, these tests are time-consuming and may not be available in all centers. CT also involves ionizing radiation. Point-of-care ultrasound has the benefit of rapid bedside use and lack of ionizing radiation.
On ultrasound, early necrotizing fasciitis presents with thickening of the subcutaneous tissue, similar to cellulitis. Fluid in the fascial layers may also be present, and a thick layer of pre-fascial fluid >4 mm has been associated with necrotizing fasciitis [2]. Subcutaneous air with dirty shadowing (Figure 14) is a characteristic but late finding in necrotizing fasciitis. These findings may be recalled using the “STAFF” mnemonic [3]:
- Subcutaneous Thickening
- Air
- Fascial Fluid
Note: It may be difficult to distinguish early cases of necrotizing fasciitis from cellulitis. Therefore ultrasound should not be used to exclude necrotizing fasciitis. Patients with findings concerning for necrotizing fasciitis require additional work-up and surgical consultation.
Figure 14. Necrotizing fasciitis on POCUS exam showing the presence of air with dirty shadowing within soft tissue (image courtesy of Dr. Di Coneybeare)
For additional reading on ultrasounding necrotizing fasciitis, see these ALiEM articles:
- As with all ultrasound applications, soft tissue POCUS is operator dependent.
- The ultrasound can only see what is scanned. You must make sure the lesion is fully imaged.
- It is difficult to differentiate between various types of fluid on ultrasound. For example, hematomas may resemble abscesses. Therefore clinical context is important.
There have been multiple studies (Table 3) that support the use of soft tissue POCUS for identification of cellulitis or abscess. Soft tissue POCUS has been shown to have good sensitivity and specificity. It has also been shown to be superior to clinical assessment in several pediatric studies.
POCUS can also reduce the length of stay (LOS) for our patients. In one pediatric study including 3,094 children suspected of a soft tissue infection who underwent either POCUS or radiology department ultrasound, POCUS was shown to have a shorter median LOS by 73 minutes (95% CI 52.4-93.6 min) [4].
| Study | N | Methods | POCUS Sensitivity (95% CI) | POCUS Specificity (95% CI) | Conclusions |
|---|---|---|---|---|---|
| Gottleib et al., Ann Emerg Med 2020 [5] | 2,656 | Systematic review of adult and pediatric studies | 94.6% (89.4-97.4%) | 85.4% (78.9-90.2%) | POCUS has good diagnostic accuracy. Led to correct change in management in 10% of cases. |
| Lam et al., J Emerg Med 2018 [6] | 327 | Prospective cohort study of children 6mo-18yrs comparing clinical assessment to POCUS | 90.3% (83.4-94.7%) | 80% (70.0-87.4%) | POCUS changed management in 22.9% of cases* |
| Subramaniam et al., Acad Emerg Med 2016 [7] | 800 | Systematic review of adult and pediatric (patients from birth – 21yrs) studies | 97% (94-98%) | 83% (75-88%) | POCUS may assist physicians in distinguishing cellulitis versus abscess. |
| Adams et al., J Pediatr 2015 [8] | 151 | Prospective cohort study of patients 3mo-21yrs comparing clinical assessment to POCUS | 96% (90-99%) | 87% (74-95%) | POCUS changed management in 27% of cases.** For every 4 ultrasounds performed, 1 correct change in management. |
| Sivitz et al., J Emerg Med 2009 [9] | 50 | Prospective cohort study of children <18yrs comparing clinical assessment to POCUS | 90% (77-100%) | 83% (70-97%) | POCUS changed management in 22% of cases. |
Table 3. Studies comparing soft tissue POCUS to clinical assessment in the management of soft tissue infections.
* Change in management after POCUS defined by the following:
- Changed incision location/size
- Added packing
- Medical to surgical management
- Surgical to medical management
- Consultation of specialist
- Other
** Change in management defined as when the ultrasound diagnosis was discordant from the physical exam and matched the ultimate lesion classification.
Case Resolution
After reviewing the literature, you decide to perform a POCUS to evaluate for skin abscess. You place a linear, high-frequency transducer over the patient’s affected area and you observe the following:
Video 6. Soft tissue ultrasound showing an abscess with heterogeneous appearance and irregular borders with posterior acoustic enhancement, surrounding soft tissue haziness, cobblestoning
ED Course
The patient underwent successful incision and drainage of the abscess, and she was discharged home with antibiotics.
Learn More…
References
- Tay ET, Ngai KM, Tsung JW, Sanders JE. Point-of-Care Ultrasound on Management of Cellulitis Versus Local Angioedema in the Pediatric Emergency Department. Pediatr Emerg Care. 2022 Feb 1;38(2):e674-e677. doi: 10.1097/PEC.0000000000002416. PMID: 34398861.
- Yen ZS, Wang HP, Ma HM, et al. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med. 2002;9:1448–1451. PMID 12460854.
- Castleberg E, Jenson N, Dinh VA. Diagnosis of necrotizing faciitis with bedside ultrasound: the STAFF Exam. West J Emerg Med. 2014 Feb;15(1):111-3. doi: 10.5811/westjem.2013.8.18303. PMID: 24578776; PMCID: PMC3935782.
- Lin MJ, Neuman M, Rempell R, Monuteaux M, Levy J. Point-of-Care Ultrasound is Associated With Decreased Length of Stay in Children Presenting to the Emergency Department With Soft Tissue Infection. J Emerg Med. 2018 Jan;54(1):96-101. doi: 10.1016/j.jemermed.2017.09.017. Epub 2017 Oct 27. PMID: 29110982.
- Gottlieb M, Avila J, Chottiner M, Peksa GD. Point-of-Care Ultrasonography for the Diagnosis of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis. Ann Emerg Med. 2020 Jul;76(1):67-77. doi: 10.1016/j.annemergmed.2020.01.004. Epub 2020 Feb 17. Erratum in: Ann Emerg Med. 2022 Jan;79(1):90. PMID: 32081383.
- Lam SHF, Sivitz A, Alade K, Doniger SJ, Tessaro MO, Rabiner JE, Arroyo A, Castillo EM, Thompson CA, Yang M, Mistry RD. Comparison of Ultrasound Guidance vs. Clinical Assessment Alone for Management of Pediatric Skin and Soft Tissue Infections. J Emerg Med. 2018 Nov;55(5):693-701. doi: 10.1016/j.jemermed.2018.07.010. Epub 2018 Aug 28. PMID: 30170835; PMCID: PMC6369916.
- Subramaniam S, Bober J, Chao J, Zehtabchi S. Point-of-care Ultrasound for Diagnosis of Abscess in Skin and Soft Tissue Infections. Acad Emerg Med. 2016 Nov;23(11):1298-1306. doi: 10.1111/acem.13049. Epub 2016 Nov 1. PMID: 27770490.
- Adams CM, Neuman MI, Levy JA. Point-of-Care Ultrasonography for the Diagnosis of Pediatric Soft Tissue Infection. J Pediatr. 2016 Feb;169:122-7.e1. doi: 10.1016/j.jpeds.2015.10.026. Epub 2015 Nov 10. PMID: 26563535.
- Sivitz AB, Lam SH, Ramirez-Schrempp D, Valente JH, Nagdev AD. Effect of bedside ultrasound on management of pediatric soft-tissue infection. J Emerg Med. 2010 Nov;39(5):637-43. doi: 10.1016/j.jemermed.2009.05.013. Epub 2009 Aug 8. PMID: 19665335.
ALiEM AIR Series | Psychosocial Module 2024
Welcome to the AIR Psychosocial Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to psychosocial emergencies in the Emergency Department. 3 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 2 Honorable Mentions. We recommend programs give 1 hours of III credit for this module.
AIR Stamp of Approval and Honorable Mentions
In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.
Take the AIR Psychosocial Module at ALiEMU
Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.
Highlighted Quality Posts: Psychosocial
| Site | Article | Author | Date | Label |
|---|---|---|---|---|
| Rebel EM | Low Dose vs Standard Dose Take-Home Buprenorphine From the ED | Tara Persaud Holmes, MD, MBA | 5 June 2023 | AIR |
| Don’t Forget the Bubbles | Medical Emergencies in Eating Disorders | Owen Hibberd, Kat Priddis | 29 Sep 2023 | HM |
| RCEM Learning | Acute Dystonia | Esther Wilson | 12 Aug 2023 | HM |
(AIR = Approved Instructional Resource; HM = Honorable Mention)
If you have any questions or comments on the AIR series, or this AIR module, please contact us!
Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275
ALiEM AIR Series | Renal Module (2023)
Welcome to the AIR Renal/GU Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to renal / GU emergencies in the Emergency Department. 6 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 3 AIR and 3 Honorable Mentions. We recommend programs give 3 hours of III credit for this module.
AIR Stamp of Approval and Honorable Mentions
In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.
Take the AIR Renal/GU Module at ALiEMU
Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.
Highlighted Quality Posts: Renal / GU
| Site | Article | Author | Date | Label |
|---|---|---|---|---|
| EMCrit | Acute Kidney Injury | Josh Farkas | March, 16, 2023 | AIR |
| EMCrit | Hepatorenal Syndrome | Josh Farkas | April 3, 2023 | AIR |
| EM Docs | Urine trouble: approach to pediatric UTI | Joe Ravera | December 7, 2022 | HM |
| EM Docs | Testicular Torsion | Brit Long | August 8, 2023 | HM |
| EM Ottawa | Testicular torsion | Alex Viau | July 27, 2023 | HM |
(AIR = Approved Instructional Resource; HM = Honorable Mention)
If you have any questions or comments on the AIR series, or this AIR module, please contact us!
Reference
- Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275
ACMT Toxicology Visual Pearls: The Kitchen Cabinet High
What is the primary toxin in the substance above?
- Solanine
- Myristicin
- Lysergic acid amide
- Phytolacca toxin
Top 3 SOAR Blog Posts on Pediatric Respiratory Infectious Disease
There has been a well-documented growth in the use of FOAM in graduate medical education [1-4]. The decentralized nature of FOAM along with concerns with the lack of peer review make the assessment of the quality of information difficult. Several years ago, a group of physicians set out to solve these problems by modifying the traditional systematic review format, and created the Systematic Online Academic Resource (SOAR) review. The SOAR review aims to “systematically identify online resources by topic…[and] assess the quality of these resources with a validated tool, and collate links.” [5]
Our review, “Systematic online academic resource (SOAR) review: Pediatric respiratory infectious disease,” [6] is the fourth in the AEM Education and Training series – and the first focusing on pediatrics. We identified 36 high-quality blog posts on this topic.
Previous SOAR reviews included the following:
- Renal and Genitourinary (ALiEM discussion)
- Endocrine, Metabolic, and Nutritional Disorders (ALiEM discussion)
- Sickle Cell Disorders
What were the top 3 posts for pediatric respiratory ID?
| rMETRIQ Score | Topic | Blog/Podcast Post | Date of Publication |
|---|---|---|---|
| 20 | Epiglottitis | Radiopaedia: Epiglottitis | 1/29/10 |
| 19 | Strep pharyngitis | emDOCs Podcast – Episode 27: An Understated Myth? Strep Throat & Rheumatic Fever | 4/27/21 |
| 19 | Hand-foot-and-mouth disease | Radiopaedia: Enterovirus 71 | 1/24/14 |
How can I find the entire list of the 36 high-quality blog posts?
Looking for a blog post on bronchiolitis? Pneumonia? Croup? Look no further! You can view these high-quality blog posts in our SOAR publication (subscription required) [6]. To make it easier, you can also identify these resources by topic on PEMBlog with Dr. Brad Sobolewski (coauthor of the SOAR review):
How did we arrive at 36 blog posts?
Using 177 search terms, our initial search yielded 44,897 resources, 441 of which met criteria for quality assessment.
- 36 of the 441 blog posts reached the high-quality cutoff score of ≥16 using the rMETRIQ scoring tool.
- 67 of the 441 blog posts had an rMETRIQ score of ≤7, meeting the threshold for poor quality.
- Similar to prior SOAR reviews, there was an uneven distribution of blog posts for each topic.
- For all of the posts reviewed, the highest mean scores were seen in the first 3 questions of the rMETRIQ tool, which relate to the “Content” domain (vs. the “Credibility” and “Review” domains).
- Only 5 of the 441 posts specified an intended audience level.
How do our findings compare to prior SOAR Reviews?
| Renal | Endocrine | Sickle Cell | Pediatric Resp ID | |
|---|---|---|---|---|
| # Reviewed | 341 | 756 | 53 | 441 |
| High Quality | 34 (10%) | 121 (16%) | 8 (15%) | 36 (8%) |
| Poor Quality* | NA | NA | 11 (21%) | 67 (15%) |
* Poor quality was not assessed in the first 2 SOAR reviews
Special thanks to SOAR coauthors Brad Sobolewski, Cindy Roskind, Andrew Grock, JooYeon Jung, Shirley Bae, and Lisa Zhao.
References
- Purdy E, Thoma B, Bednarczyk J, Migneault D, Sherbino J. The use of free online educational resources by Canadian emergency medicine residents and program directors. Can J Emerg Med. 2015;17(2):101-106. doi:10.1017/cem.2014.73. PMID 25927253
- Mallin M, Schlein S, Doctor S, Stroud S, Dawson M, Fix M. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014;89(4):598-601. doi:10.1097/ACM.0000000000000170. PMID 24556776
- Thurtle N, Banks C, Cox M, Pain T, Furyk J. Free open access medical education resource knowledge and utilisation amongst emergency medicine trainees: a survey in four countries. Afr J Emerg Med. 2016;6(1):12-17. doi:10.1016/J.AFJEM.2015.10.005. PMID 30456058
- Reiter DA, Lakoff DJ, Trueger NS, Shah KH. Individual interactive instruction: an innovative enhancement to resident education. Ann Emerg Med. 2013;61(1):110-113. doi:10.1016/J. ANNEMERGMED.2012.02.028. PMID 22520994
- Grock A, Bhalerao A, Chan TM, Thoma B, Wescott AB, Trueger NS. Systematic online academic resource (SOAR) review: renal and genitourinary. AEM Educ Train. 2019;3(4):375-386. doi:10.1002/ aet2.10351. PMID 31637355
- Belfer J, Roskind CG, Grock A, et al. Systematic online academic resource (SOAR) review: Pediatric respiratory infectious disease. AEM Educ Train. 2024;8(1):e10945. Published 2024 Feb 21. doi:10.1002/aet2.10945. PMID 38510728
Pigtail catheter for pleural drainage: Tips to minimize complications
Traditionally large-bore tube thoracostomy has been the standard of care for treating many acute intrathoracic pathologies [1]. However, the advent of less invasive small-bore chest tubes, also known as pigtail catheters, has gradually led to a paradigm shift. Pigtails provide a less invasive and often better tolerated alternative to traditional chest tubes and allow for adequate treatment of pneumothoraces and uncomplicated pleural effusions [1-5]. Unfortunately, these less invasive catheters are not without complications – both unique and similar to traditional chest tubes.
Case
A 48 year-old male with a history of hypertension and polysubstance abuse presented to the emergency department (ED) for shortness of breath and was found to have a left sided parapneumonic pleural effusion (Figure 1). The patient underwent thoracentesis and placement of a pigtail catheter using the Seldinger technique to drain the fluid collection. Pigtail catheter placement was confirmed by chest x-ray (Figure 2).
Figure 1: Chest x-ray with left sided pleural effusion
Figure 2: Chest x-ray with the pigtail catheter in the left chest
Case Progression
Despite pigtail catheter placement, there was minimal drainage from the catheter. In collaboration with the inpatient team, intrapleural thrombolytics were administered via the pigtail catheter did not resolve the issue. Although the patient’s chest x-ray did improve after the procedure, the patient continued to deteriorate clinically and became increasingly hypoxic.
A CT angiogram was then performed and showed that the pigtail catheter had been accidentally introduced through the lung parenchyma and was lodged in the left main stem bronchus (Figure 3). This was confirmed on bronchoscopy (Figure 4).
Figure 3: Chest CT angiogram showing the pigtail catheter (arrow) in the left mainstem bronchus
Figure 4: Bronchoscopy view of the left mainstem bronchus showing the pigtail catheter
This case highlights one of the more rare and potentially severe complications of small-bore chest tubes. With the increasing utilization of such devices, this case highlights the need for better education about the indications, complications, and troubleshooting approaches with these pigtail catheters.
Complications
The overall complication rate for small-bore catheters is lower than their large-bore counterparts, partly because of their smaller caliber. Also unlike traditional large-bore tube thoracostomy, the lack of tactile feedback (not feeling the pleural puncture ‘pop’ with Kelly clamps and then identifying the intrapleural space with the finger) can lead to malpositioning complications. Both approaches, however, share common complications:
- Most common complication: Chest tube kinking and obstruction [6, 7, 10]
- Due to the small caliber of the pigtail catheter, it can easily become twisted or kinked between the pleura and lung parenchyma, obstructed within lung fissures, or kinked externally between the body and environment [9].
- Obstruction may also occur from clotted blood [9] or pleural effusion loculations [12, 13] within the catheter lumen.
- For loculated effusions and empyemas, an interdisciplinary inpatient discussion should weigh the pros and cons of intrapleural thrombolytics versus surgical drainage and pleurodesis.
- One often used thrombolytic regimen is the MIST-II protocol, which involves the combination of alteplase (tPA) 10 mg BID plus dornase alfa (DNase) 5 mg BID [13, 14].
- Laceration of tissue/vessel [2, 3, 6, 8]
- Can be prevented by using standard landmarks and inserting above the rib margin
- Air emboli [2, 3, 6, 9]
- Thought to be due to parenchymal injury resulting in a fistula involving the pulmonary vessels
- Parenchymal injury [9]
References
- Gammie JS, Banks MC, Fuhrman CR, et al. The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 1999;3(1):57-61. PMID: 10323171
- Saqib A, Ibrahim U, Maroun R. An unusual complication of pigtail catheter insertion. Journal of Thoracic Disease. 2018;10(10):5964-5967. doi:https://doi.org/10.21037/jtd.2018.05.65
- Broder JS, Al-Jarani B, Lanan B, Brooks K. Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety. The Journal of Emergency Medicine. 2020;53(3). doi:https://doi.org/10.1016/j.jemermed.2019.10.003
- Vetrugno L, Guadagnin GM, Barbariol F, et al. Assessment of Pleural Effusion and Small Pleural Drain Insertion by Resident Doctors in an Intensive Care Unit: An Observational Study. Clinical Medicine Insights Circulatory, Respiratory and Pulmonary Medicine. 2019;13:1179548419871527. doi:https://doi.org/10.1177/1179548419871527
- Kulvatunyou N, Vijayasekaran A, Hansen A, et al. Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend. J Trauma. 2011;71(5):1104-1107. doi:https://doi.org/10.1097/ta.0b013e31822dd130
- Remérand F, Luce V, Badachi Y, Lu Q, Bouhemad B, Rouby JJ. Incidence of Chest Tube Malposition in the Critically Ill. Anesthesiology. 2007;106(6):1112-1119. doi:https://doi.org/10.1097/01.anes.0000267594.80368.01
- Horsley A, Jones L, White J, Henry M. Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains. Chest. 2006;130(6):1857-1863. doi:https://doi.org/10.1378/chest.130.6.1857
- Hyo Jin Kim, Yang Hyun Cho, Gee Young Suh, Jeong Hoon Yang, Jeon K. Subclavian Artery Laceration Caused by Pigtail Catheter Removal in a Patient with Pneumothorax. The Korean Journal of Critical Care Medicine. 2015;30(2):119-122. doi:https://doi.org/10.4266/kjccm.2015.30.2.119
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