Bedside fluoroscopy for the detection of foreign bodies.

OBJECTIVE: To determine the sensitivity and specificity of portable fluoroscopy for foreign-body detection using an ex-vivo experimental model. METHODS: A prospective, randomized masked investigation was performed to characterize foreign-body detection in cubes of beef. Three emergency physicians (EPs) independently used a portable fluoroscope to determine the presence or absence of various foreign bodies in ten cubes of beef (approximately 6 cm on each side). Six different groups of foreign bodies were examined: glass, wood, graphite (pencil lead), metal (needle), plastic, and gravel. An independent observer placed the six objects randomly into each set of ten beef cubes. One hundred observations were made by each physician using sets of ten beef cubes at a time. RESULTS: Fluoroscopy detected 117 of 180 foreign bodies (sensitivity 65%; 95% CI 58-72%), including all cubes of beef embedded with gravel, metal, and glass. Graphite was detected 27 of 30 times (sensitivity 90%; 95% CI 74-98%). None of the plastic or wooden foreign bodies was identified despite magnification techniques and real-time imaging (sensitivity 0%; 95% CI0-12%, each). Of the 120 cubes of meat with no foreign body, two false-positives were recorded (specificity 98%; 95% CI 94-100%). The overall positive predictive value and negative predictive value of fluoroscopy were 98% and 65%, with 95% CIs of 94-100% and 58-72%, respectively. Interobserver agreement between the three EPs was considered excellent (kappa = 0.75). CONCLUSION: Bedside fluoroscopy lacks sufficient sensitivity to rule out many foreign bodies in the ED. Its use should be limited to suspected gravel, glass, pencil lead, and metallic objects, which are known to be radiopaque.

Clinical validity of ultrasound in children with suspected appendicitis.

STUDY OBJECTIVE: To determine the accuracy of diagnosing appendicitis in the pediatric population by using graded compression ultrasonography. DESIGN: Retrospective case review. SETTING: University-affiliated community hospital with an emergency department census of approximately 19,000 pediatric visits per year. TYPE OF PARTICIPANTS: Ninety-eight children (age less than 13 years) with clinically suspected appendicitis who had graded compression sonographic studies during the 24-month study period. INTERVENTIONS: Medical records were reviewed for patient demographics, presenting signs and symptoms, sonographic findings, surgical results, and hospital course. Patients who did not undergo surgery were followed up by telephone for a minimum of two months. RESULTS: Ninety-eight children (42 boys and 56 girls; age range, 2 to 12 years; mean age, 8.0 years) with clinical signs and symptoms of acute appendicitis were examined sonographically. Of the 26 patients whose appendicitis was verified at surgery, ultrasound was positive in 22, with an overall sensitivity of 85%. Of the 72 patients who did not have appendicitis, ultrasound was negative in 68, with a specificity of 94%. Two patients with false-positive ultrasound went to surgery and were found to have acute ileitis and perforated Meckel's diverticulum. The overall diagnostic accuracy was 91.8% (90 of 98). CONCLUSION: Use of ultrasound to diagnose acute appendicitis was performed with a sensitivity of 85% and a specificity of 94%. This allows the same accuracy in children as has been reported with adults.