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CEUS in gunshot wound of the liver – first experience in military mission
S64
Ultrasound in Medicine & Biology
The clinical spectrum of PsA is broad with five target areas of joints, tendons, entheses, skin and nails. Each domain will be discussed with their relevant US findings, focussing on synovitis, enthesitis and dactylitis. Specifically, features of enthesitis on US can be divided into those of reversible soft tissue inflammation and irreversible tissue damage. There is increasing use of US in evaluating nail involvement in psoriasis as this feature increases the probability of developing PsA. In patients with predominantly hand involvement, US enables differentiation of PsA from other inflammatory arthritides, such as rheumatoid arthritis, using specific extra-synovial US patterns of inflammation. Examples include peritenonitis of the extensor digitorum tendon at the metacarpophalangeal joints. Thickening of the flexor tendon pulleys may be predictive of PsA in the setting of early arthritis. Psoriatic related polyenthesitis without clinically swollen joints or increased inflammatory markers can mimic fibromyalgia with multiple tender points. US detection of enthesitis especially if power Doppler positive may assist by providing an objective assessment of disease activity. More recently, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) US Working Group has developed a PsA US enthesitis scoring system, addressing the elementary inflammatory and structural components and determining which entheseal sites should be scanned. The utility of US in monitoring disease activity in PsA to support clinical assessment will be discussed, including guidance in tapering therapy in clinical remission. The ongoing prospective US in PsA Treatment Study (UPSTREAM) aims to identify clinical and US predictors of treatment response in PsA. Future research should address issues such as the optimal combination for US screening of joints, tendons and entheses, the predictive value of subclinical US inflammatory lesions for future development of PsA and whether US provides any added prognostic value in PsA in those achieving minimal disease activity on therapy.
SESSION 13B: POCUS CEUS in gunshot wound of the liver first experience in military mission Christian Richter,1 Kerstin Schwabe,2 Michael Grunert,3 Benedikt Friemert4 1 Center for Vascular Medicine, German Federal Armed Forces Hospital ULM, Ulm, BADEN-Wu¨RTTEMBERG, Germany, 2 Department of Surgery, Federal Armed Forces Hospital Ulm, Ulm, Baden-Wu¨rttemberg, Germany, 3 Department of Radiology, Federal Armed Forces Hospital ULM, Ulm, Baden-Wu¨rttemberg, Germany, 4 Department of Trauma and Reconstructive Surgery, Federal Armed Forces Hospital ULM, Ulm, Baden-Wu¨rttemberg, Germany Purpose: Computed tomography (CT) is the gold standard technique in gunshot injuries imaging. In military missions and in case of mass casualties availability of CT scanning and capacity of airborne transporting may be limited. FAST (Focused Assessment with Sonography in Trauma) remains the primary imaging examination in abdominal trauma. Contrast-enhanced ultrasound (CEUS) could close the diagnostic gap between CT scanning and FAST and back-up shortage of diagnostic avail- abilities. Material and methods: We report a case of gunshot wound of the liver during military mission in Afghanistan. FAST and CT scanning were done as first diagnostic imaging. CEUS was performed additionally in the emergency room by CX 50 Philips ultrasoundsystem and SonoVue contrast agent. CEUS was repeated after each following operation and also done intraoperative to estimate the damage of the liver and hematoma. Results: The wound track extension of traumatic gunshot wound could not be estimated on first CEUS examination due to aerodermectasia and
Volume 45, Number S1, 2019 gas echo extended along the wound track. Subsequent CEUS after first operations revealed that the wound track echo was unenhanced in majority. CEUS effectively detected the wound tract, hematoma, and the liver area injured by the gunshot and could accurately reveal necrotic tissue in the injured area and differentiate it from normal tissue. Conclusions: Application of CEUS may provide important imaging for gunshot wound debridement in its follow up and avoid repeated CT scannings. Thus may spare time and transport capacity in millitary missions. CEUS is an interesting diagnostic tool in blunt and gunshot trauma of the abdomen.
BUCKLED: Bedside ultrasound conducted in kids with distal upper limb fractures in the emergency department (observational trial) Peter Snelling1,2,3 1 Emergency Department, Queensland Children’s Hospital, Brisbane, QLD, Australia, 2 Senior Lecturer, University of Queensland, Brisbane, QLD, Australia, 3 Emergency Department, Gold Coast University Hospital, Southport, QLD, Australia Forearm fractures in children are a common presentation to the Emergency Department. Paediatric distal forearm fractures account for almost a third of all fractures in children, with a significant proportion of these diagnosed as buckle (torus) type fractures. These fractures are unique to children, occurring due to deformation of the metaphysis within a thick and strong periosteum. Point-of-care ultrasound has increasing utility in the diagnosis of non-angulated distal forearm fractures given that it is rapid, highly accurate, well-tolerated, and does not involve ionising radiation. Emergency Nurse Practitioners are utilised in the ambulatory care area, where they provide high-quality, cost-effective care. Given that NPs are heavily relied upon for the diagnosis and management of paediatric fractures, it was hypothesised that teaching them to diagnose distal forearm buckle fractures with a rapid POCUS protocol (i.e. less than 10 minutes) could potentially lead to time and resource savings, given that these patients can be appropriately discharged in a wrist splint. During the BUCKLED observational trial, Nurse Practitioners prospectively recruited a convenience sample of more than 200 paediatric patients over a 12-month period at a tertiary paediatric hospital in Australia. Patients were enrolled between the ages of 4-16 years with a non-deformed forearm with clinically suspected fracture to be evaluated with radiograph imaging. This pilot study determined the acceptability (staff, parent, child), tolerability (pain compared to radiograph), feasibility (time of scan), and the accuracy of Nurse Practitioners to diagnose buckle fractures using point-of-care ultrasound compared to radiograph as the gold standard. Besides potential benefits in a tertiary paediatric setting, outcomes from this study may have relevance to resource limited environments. The findings from this trial will be presented, along with future directions. References: 1. Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care 2007; 23: 523-531. 2. Hubner U, Schlicht W, Outzen S, et al. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br. 2000;82 (8):1170 1173. 3. Pountos I, Clegg J, Siddiqui A. Diagnosis and Treatment of greenstick and torus fractures of the distal radius in children: a prospective randomised single blind study. J Child Orthop. 2010; 4:321-326. 4. Kozaci N, et al. Evaluation of the effectiveness of bedside pointof-care ultrasound in the diagnosis and management of distal radius fractures. American Journal of Emergency Medicine. 2015; 33:67-71.
Ultrasound in Medicine & Biology
The clinical spectrum of PsA is broad with five target areas of joints, tendons, entheses, skin and nails. Each domain will be discussed with their relevant US findings, focussing on synovitis, enthesitis and dactylitis. Specifically, features of enthesitis on US can be divided into those of reversible soft tissue inflammation and irreversible tissue damage. There is increasing use of US in evaluating nail involvement in psoriasis as this feature increases the probability of developing PsA. In patients with predominantly hand involvement, US enables differentiation of PsA from other inflammatory arthritides, such as rheumatoid arthritis, using specific extra-synovial US patterns of inflammation. Examples include peritenonitis of the extensor digitorum tendon at the metacarpophalangeal joints. Thickening of the flexor tendon pulleys may be predictive of PsA in the setting of early arthritis. Psoriatic related polyenthesitis without clinically swollen joints or increased inflammatory markers can mimic fibromyalgia with multiple tender points. US detection of enthesitis especially if power Doppler positive may assist by providing an objective assessment of disease activity. More recently, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) US Working Group has developed a PsA US enthesitis scoring system, addressing the elementary inflammatory and structural components and determining which entheseal sites should be scanned. The utility of US in monitoring disease activity in PsA to support clinical assessment will be discussed, including guidance in tapering therapy in clinical remission. The ongoing prospective US in PsA Treatment Study (UPSTREAM) aims to identify clinical and US predictors of treatment response in PsA. Future research should address issues such as the optimal combination for US screening of joints, tendons and entheses, the predictive value of subclinical US inflammatory lesions for future development of PsA and whether US provides any added prognostic value in PsA in those achieving minimal disease activity on therapy.
SESSION 13B: POCUS CEUS in gunshot wound of the liver first experience in military mission Christian Richter,1 Kerstin Schwabe,2 Michael Grunert,3 Benedikt Friemert4 1 Center for Vascular Medicine, German Federal Armed Forces Hospital ULM, Ulm, BADEN-Wu¨RTTEMBERG, Germany, 2 Department of Surgery, Federal Armed Forces Hospital Ulm, Ulm, Baden-Wu¨rttemberg, Germany, 3 Department of Radiology, Federal Armed Forces Hospital ULM, Ulm, Baden-Wu¨rttemberg, Germany, 4 Department of Trauma and Reconstructive Surgery, Federal Armed Forces Hospital ULM, Ulm, Baden-Wu¨rttemberg, Germany Purpose: Computed tomography (CT) is the gold standard technique in gunshot injuries imaging. In military missions and in case of mass casualties availability of CT scanning and capacity of airborne transporting may be limited. FAST (Focused Assessment with Sonography in Trauma) remains the primary imaging examination in abdominal trauma. Contrast-enhanced ultrasound (CEUS) could close the diagnostic gap between CT scanning and FAST and back-up shortage of diagnostic avail- abilities. Material and methods: We report a case of gunshot wound of the liver during military mission in Afghanistan. FAST and CT scanning were done as first diagnostic imaging. CEUS was performed additionally in the emergency room by CX 50 Philips ultrasoundsystem and SonoVue contrast agent. CEUS was repeated after each following operation and also done intraoperative to estimate the damage of the liver and hematoma. Results: The wound track extension of traumatic gunshot wound could not be estimated on first CEUS examination due to aerodermectasia and
Volume 45, Number S1, 2019 gas echo extended along the wound track. Subsequent CEUS after first operations revealed that the wound track echo was unenhanced in majority. CEUS effectively detected the wound tract, hematoma, and the liver area injured by the gunshot and could accurately reveal necrotic tissue in the injured area and differentiate it from normal tissue. Conclusions: Application of CEUS may provide important imaging for gunshot wound debridement in its follow up and avoid repeated CT scannings. Thus may spare time and transport capacity in millitary missions. CEUS is an interesting diagnostic tool in blunt and gunshot trauma of the abdomen.
BUCKLED: Bedside ultrasound conducted in kids with distal upper limb fractures in the emergency department (observational trial) Peter Snelling1,2,3 1 Emergency Department, Queensland Children’s Hospital, Brisbane, QLD, Australia, 2 Senior Lecturer, University of Queensland, Brisbane, QLD, Australia, 3 Emergency Department, Gold Coast University Hospital, Southport, QLD, Australia Forearm fractures in children are a common presentation to the Emergency Department. Paediatric distal forearm fractures account for almost a third of all fractures in children, with a significant proportion of these diagnosed as buckle (torus) type fractures. These fractures are unique to children, occurring due to deformation of the metaphysis within a thick and strong periosteum. Point-of-care ultrasound has increasing utility in the diagnosis of non-angulated distal forearm fractures given that it is rapid, highly accurate, well-tolerated, and does not involve ionising radiation. Emergency Nurse Practitioners are utilised in the ambulatory care area, where they provide high-quality, cost-effective care. Given that NPs are heavily relied upon for the diagnosis and management of paediatric fractures, it was hypothesised that teaching them to diagnose distal forearm buckle fractures with a rapid POCUS protocol (i.e. less than 10 minutes) could potentially lead to time and resource savings, given that these patients can be appropriately discharged in a wrist splint. During the BUCKLED observational trial, Nurse Practitioners prospectively recruited a convenience sample of more than 200 paediatric patients over a 12-month period at a tertiary paediatric hospital in Australia. Patients were enrolled between the ages of 4-16 years with a non-deformed forearm with clinically suspected fracture to be evaluated with radiograph imaging. This pilot study determined the acceptability (staff, parent, child), tolerability (pain compared to radiograph), feasibility (time of scan), and the accuracy of Nurse Practitioners to diagnose buckle fractures using point-of-care ultrasound compared to radiograph as the gold standard. Besides potential benefits in a tertiary paediatric setting, outcomes from this study may have relevance to resource limited environments. The findings from this trial will be presented, along with future directions. References: 1. Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care 2007; 23: 523-531. 2. Hubner U, Schlicht W, Outzen S, et al. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br. 2000;82 (8):1170 1173. 3. Pountos I, Clegg J, Siddiqui A. Diagnosis and Treatment of greenstick and torus fractures of the distal radius in children: a prospective randomised single blind study. J Child Orthop. 2010; 4:321-326. 4. Kozaci N, et al. Evaluation of the effectiveness of bedside pointof-care ultrasound in the diagnosis and management of distal radius fractures. American Journal of Emergency Medicine. 2015; 33:67-71.