Emergency Interventional Sonography in Children - SD

Introduction to Emergency Sonography and Intervention in Children

Good day.

My name is Dr. William Shields from Nationwide Children's Hospital in Columbus, Ohio, and today we're gonna discuss emergency sonography and intervention in children and the use of sonography in supporting interventional radiological care in emergent or urgent situations that involve children and to a large degree adults as well.

Today we're going to speak about emergency interventional sonography in children and the applications of sonography for urgent and emergent situations. We'll focus on practical aspects that we encounter in pediatric radiology and to a lesser degree in the care of adults with either congenital disorders or unique situations that require children's hospital support and care in the emergency or urgent setting where interventional radiology is called upon to support the care of the patient and particularly in situations where sonography provides unique and or critical advantage in the performance of the interventional radiological procedures.

These elements together allow us to provide more successful care and particularly successful partnership with medical and surgical disciplines.

We'll focus on seven procedures today, vascular access, the management of empyema in the chest, emergent pericardial effusion, drainage abscess drainage, percutaneous nephrostomy placement, cerebral spinal fluid pseudotumor management in patients with ventricular peritoneal shunts. And lastly, some unusual situations where foreign body removal is requested on an emergent basis.

Emergency Vascular Access

We will look first at emergency vascular access. Now in children we tend to utilize vascular access emergently in the pediatric intensive care unit in patients who are in shock either from sepsis, cardiogenic shock, and most often we are requested to perform vascular access for femoral venous access. And most of the time since the patient's in shock, the clinicians have had a difficult time gaining arterial access and we support the patient with arterial access in addition to central venous access.

Very important in these patients is to always have a plan B, an alternative plan where if femoral vascular access is not successful, then we will approach either subclavian or jugular vascular access in the need intensive care unit, usually it's in the setting of bowel perforation, necrotizing enterocolitis or sepsis that were requested to support the team with vascular access.

Other children who are able to come down to the radiology department may have sepsis with no peripheral venous access and these cases do not necessarily need to be performed at the bedside. But most commonly in the interventional radiology suite and patients who require vascular access urgently are requested to have our support because they've had previous vascular access and we refer to these as vascular access casualties where they had thrombosis with scarring and stenosis or occlusion of vessels. Precluding traditional central venous catheter access.

The three patient populations we tend to see this in are in the cardiac patients, cystic fibrosis patients and patients with short gut syndrome with TPN dependent situations.

So first ultrasound guided vascular axis, the most important portion of the procedure is maintaining visualization of the tip of the needle at all times and ideally proceeding with a single wall puncture through the superficial portion of the vein wall. As we see with the needle on the bevel tip essentially located within the lumen, this hockey stick type probe gives us tremendous advantage that is very flexible and ergonomically very advantageous for vascular access in both arm, neck and vascular excess in the femoral vessels.

The technique that we utilize incorporates freehand technique and we begin by finding the target with the transducer. It's very important to visualize the back wall of the vessel in crisp detail. This lets us know that we are centrally located in the long axis view. Then we fix the transducer hand on the target, stabilizing our hand with the transducer and very important point we avoid moving both hands simultaneously. We either fix the transducer and move the needle in a subcutaneous plane or we sweep the needle back and forth until it finds the sound plane or we fix the needle in place and move the transducer to find the orientation that we are in misguidance for. For correction, then we follow the needle tip and again, always follow the bevel and the needle tip and just like a plane landing in the, in a nice oblique plane coming down to the superficial wall. And then with a smooth puncture, a single wall puncture technique, two different planes that we provide vascular access the majority of the time it is in the longitudinal plane or the long axis plane where we see the tip of the needle superficial to the vessel wall and then centrally located within the lumen, always looking for the come tail artifact at the tip of the needle, whether superficial or within the vascular lumen.

In the short axis view or the transverse plane, we see the needle as a dot superficial to the vein wall indenting the vein wall and then puncturing into the vein wall essentially located in the lumen.

Pitfalls and artifacts are important for us to understand. The two most common in vascular axis are the oblique crosscut artifact and the beam width volume averaging artifact. We'll look at both of these in animation and graphic forms. Here we see two still images of the oblique crosscut artifact. In the image top left, we see the full alignment of the needle and the bottom right image. With slight movement and rotation of the transducer, we see that we lose the proximal and distal portions of the needle and this is a critical pitfall. Here we see the needle in good alignment, but a slight rotation of the transducer. We lose the proximal and distal portions of the needle.

Now when performing femoral vascular access, particularly in the very small child or the child who is small and in shock that has markedly attenuated vessels, many times the vascular lumen is one millimeter or less and we're required to gain access to that lumen. As you see in this long, long axis view of the common femoral vein, the number one and number two indicators indicate the locations where we prefer to proceed with access first in the ascending portion of the femoral vein and note is made that the femoral head is below or deep to the vein. So we would approach first in site number one and if that fails then we are left with site number two. Site number two is always our backup site and as we see with the arrow, it is lined up very nicely in the plane of needle access and the direction of the descending portion of the common femoral vein. This image shows the arrow pointing towards the portion of the femoral vein in the ascending portion that we'll target.

Now we see the bevel of the needle indenting the vein wall and then next with the bevel clearly centered within the vein wall, notice the small size of this infant vein. The width of the vein is essentially as long as the bevel is, and so we have very little room for failure. Very important to notice that we are in both with visual and tactile feedback. We feel the vein wall pop and we see the vein wall in dent and then release and then many times we can see blood moving retrograde in the needle once the needle is in place.

Another maneuver that is very helpful is to watch the G wire, exit the needle tip and move smoothly in an ascending fashion in the vein towards a more proximal position in the iliac region and the arrow is on the oh one eight inch G wire. In very small children, one maneuver that works out very well. Here we have two images of the common femoral vein, the top one prior to access in the bottom one with the needle and the guidewire in place and the image on the right shows that we are able in very small children where the black arrow is the straight arrow. We can make a skin puncture well below the diaper line to decrease the risk of vascular infection and bloodborne infection regarding or associated with the vascular access procedure and long main, long-term maintenance of the vascular lines. And we can see the curved arrow is where the needle would actually enter the vein. So we have a nice long tunnel in these very small children that the vascular access needles allow us the opportunity to produce a single puncture tunneled central venous catheter and avoid the diaper line and the secondary contamination.

In this animation we see the classic long axis approach or the longitudinal approach, single wall puncture technique with the needle and the guide wire advancing in the vascular lumen.

Here we see volume averaging artifact. We approach the needle into the vein and it looks like the needle is in the lumen, but then we look either in the transverse plane or move the transducer in the long axis for you to see that we are adjacent to the vascular lumen, not within the vascular lumen.

One last pitfall. If we move too slowly, we can actually dissect the intima from the media and then have secondary displacement of the wire in a subintimal dissection plane that will cause complications to follow. So again, we wanna move in with a brisk maneuver to avoid this pitfall when we're not approaching femoral venous access.

The most common approach in the interventional radiology department is to use the arm approach for central venous access or a PICC line, a peripherally inserted central venous catheter. Here we see in that long axis view the 21 gauge needle accessing following the transducer placed in the sound beam with this very lightweight hockey stick probe. And here we see the needle tip clearly in the basilic vein with good central location with a single wall puncture technique.

Management of Empyema in the Chest

The next procedure is something that occurs not uncommonly in patients that have complicated pneumonia and respiratory distress and their pleural cavities have either fluid collections or emia with sepsis and we are called not infrequently in the urgent situation to relieve this fluid collection to support the resolution of the respiratory distress and remittance fevers.

Here we have the reality that sonography gives us a key advantage in evaluating these emmic cavities and the changes in the fluid over time and it allows us to prognosticate for fibrinolytic therapy. For fibrinolytic therapy. Dosing two milligrams of TPA is our standard dose given in 20 liters of saline and allowed to maintain its dwell time for one hour. If we do this every 12 hours, we usually will have success within the first one or two doses and two or three days of this regimen will usually clear even the largest of themic cavities.

This regimen in our practice has given us greater than 95% success in treatment of emis and essentially less than 5% of our patients ever go to surgery. This works when we have favorable FIS or fluid dynamics and we'll go through this graphically in the following slides and again, sonography allows us to evaluate in a prospective fashion. It allows to prognosticate very clearly to determine whether the pleural fluid can be drained effectively with or without fibrinolytic therapy and whether the empyemia can be treated. Nonsurgically grade one allows us without any FIS collections to put a chest tube in and drain that collection immediately and completely at the time of drainage, we will leave a drain in place for 24 hours or 48 hours until drainage stops grade two PY is with early fieris change and early organization. We can put a chest tube in institute TPA and we will usually resolve the PY fully with this chest tube and TPA therapy Grade three PY is that are heavily organized. We will give a trial of fiber lytic therapy, however, usually these patients if required will need surgery to clear that solidified and heavily organized collection.

Here we see a young child with left lower lobe pneumonia and a large empyemia cavity. Here on the CT we see the empyema, but the CT does not help us characterize this empyema for a prognostication purposes. Here we see on the ultrasound the arrow is on the unorganized monic effusion and again in the the absence of FIS organization, this fluid collection can be drained completely at the time of chest tube placement.

Here we have the needle with ultrasound guidance placed in the pleural fluid collection and this arrow is on the the pleural surface of the lung as it reinflates and we can see that the monic effusion is completely drained.

Here we have another case, similar situation, similar CT appearance. Now the ultrasound shows us that this is beginning to organize in a grade two organization fashion FIS organization, but the arrows now are on the dark fluid lockes that tell us that the TPA will indeed work and successfully resolve this organizing. FIS chest tube is in place. This is the CT scan following four days of fibrinolytic therapy and we can see that there is no evidence of any residual plural component.

Even in cases where we may have small residual organized EMAs, this small amount of organization will be densely organized. There won't be any free fluid and if we look sonographic, we won't see anything that's drainable. Antibiotics will penetrate this successfully and we can remove the chest tube and have greater than 95% resolution of the emmic cavity as a as an excellent result.

Here we have a patient that was in severe respiratory distress with a tension hydro thax and py, a cavity and you can see displacement of the mediastinal and cardiac structures to the left sono graphically. We see this as a grade two with fluid-filled cavities and FIS organization. We know by looking at this, that fbri lytic therapy will be successful. So at this point with sonographic guidance, we'll place our needle through the sheath will then place a wire and a coaxial four or five French U and that's the name of the catheter, YUEH. The four or five French U needle and sheath system provides this great single puncture access the needle removed and then through the sheath we can put a G wire, then proceed with fluoroscopically guided placement of dilators and the catheter.

Catheter is in place TPA for a few days and once drainage stops, then we can see that approximately one month later the amma is essentially cleared with a small amount of residual pleural thickening. The patient is afebrile and no longer requires oxygenation.

These two images demonstrate the two phases, grade two to grade three and again as we mentioned, the grade two image on the left will be responsive to fibrinolytic therapy with greater than 95% success. And grade three on the right is going to likely require surgical management. We will still put a chest tube in there and try through the pigtail catheter to have success with fibrinolytic therapy, but greater than 50% of the time that is not successful.

Emergent Pericardial Effusion Drainage

Now in some situations we are requested by the cardiologist to support the patient with emergent pericardiocentesis when either the patient is very small or the effusion is in a situation where they request our help with sonographic placement. Here we have a young child with congenital heart disease and is having difficulty with respiratory distress and cardiac output due to a large effusion. Here we see the arrow on this pericardial effusion and with an animation in a cine clip we see the changes in the pericardial effusion with motion of this small child and so we were asked to support the patient with placement of the drainage catheter.

Here we see with the curved arrow, the needle is in place approaching the pericardial surface and we're administering lidocaine for local anesthesia in this patient that was under deep sedation for this procedure. Next we see the needle in place and this is the vascular sheath In this sit situation, this is a 14 gauge angio catheter that is in place in the right pericardial recess and we can see that the needle has been removed. We have the plastic sheath in place and the arrow is on the tip of this vascular sheath with no cutting surface to injure the patient.

A few slides and we will go through this in greater detail when we discuss small abscess drainage, but this is the 14 gauge angio catheter and we'll illustrate how we gain access to the pericardial effusions with a coaxial technique beginning with the 14 gauge Angie catheter. So the Angie catheter is then placed into the pericardial effusion. Once it's accessed, the sharp needle is removed then in a coaxial fashion a five French pigtail catheter without any stiffening wires or trocars is then advanced in a coaxial fashion exiting with the soft tip of the catheter. It then curls as it exits through this 14 gauge Angie catheter sheath and you can see with the five French catheter in place and with a cine loop, we see the catheter coming from the skin surface into the pericardial effusion and clearly missing the right atrial margin.

Once that catheter, again with no sharp instrumentation, it can be advanced fully into the pericardial recess, then repositioned into a good inferior position and secured to the chest wall for drainage. This child drained 75 ccs of pericardial fluid over a three day period and then it was removed and the child was sent home.

Abscess Drainage

Abscess drainage is something that occurs uncommonly in the emergent situation but quite frequently in the rather urgent situation. Most patients are not frankly septic but require abscess drainage to prevent septic shock. Ultrasound guidance is clearly the favored technique in our institution as it is much faster and allows us more control and accuracy when compared to CT guided abscess drainage.

One of the critical components for successful ultrasound guided abscess drainage is lidocaine placement into the abscess wall. We access again with the four or a five French U coaxial needle in sheath system and then through the sheath we can then displace the O three five inch super stiff G wire and then over that dilate up to give us either access for 10, 12 or 14 french pigtail catheters.

Now we can drain abscesses either t abdominally or intra ally when they're in the in the abdominal and pelvic cavities. Trans rectal abscess is another option. We have two approaches that we will demonstrate. One is using a rectal ultrasound probe and needle guide and the second is a free hint technique using a transabdominal approach with a catheter approaching through a trans rectal approach.

Here we see the classic abdominal abscess following a ruptured appendicitis with a large right paracolic gutter abscess image. On the bottom right shows the four French U needle and sheath system in position and now top left image we see the G wire coming out of the sheath and bottom right image the abscess is being drained following catheter placement.

Transrectal drainage again is pursued in two different techniques. One transrectal ultrasound guidance with a needle guide and a classic senu approach with a needle and a G wire and dilators. The second approach may be a simpler approach in hands of operators that are comfortable with this approach where we scan soo graphically using a transabdominal approach. We may need to fill the bladder with a Foley catheter and we will demonstrate a simplified trocar technique for accessing the abscess.

Here we have in the longitudinal plane the bladder anteriorly and the deep pelvic abscess posteriorly. Now we have a drainage catheter that is placed into the rectum and the cutting trocar is not exiting the tip of the catheter. If you notice in this blue catheter there's a stiffening trocar, a blunt stiffening trocar, but the cutting trocar is not displaced distally. With this blunt tip, then we can indent the rectal wall and indent the inferior abscess wall. Then once we know we are in position, we can see things clearly sono graphically. Then we can introduce the cutting trocar puncture through the inferior abscess wall and then advance the catheter into the abscess. Once the catheter and the stiffener are advanced, then we can deploy the catheter off of the stiffen trocar, deploy the catheter into the abscess cavity and then drain the abscess.

Here we have a cine loop with the catheter clearly in place in the abscess cavity. Now we are draining the abscess cavity and then after it is drained we can then use the catheter to lavage the abscess to facilitate breaking the fever curve.

The second approach for trans rectal abscess, as we see with this CT scan the abscess posterior to the bladder. Here we have the abscess cavity. Now using a trans rectal transducer and a needle guide, we can puncture through the abscess. As we see here, the needle now is within the abscess G wire exits from the needle and then we can dilate up and place our drainage catheter and then succeed in complete drainage of the cavity followed by lavage as we see in this frame.

Small Abscesses

What do we do when we have small abscesses? Some, some nice technical tricks that sonography gives us the ability to perform and we mentioned earlier the coaxial technique of using a 14 gauge angio catheter followed by coaxial placement of a five French drainage catheter. This will be demonstrated as a technique where we drain these small abscesses. These are best used with abscesses in the size of two to four centimeters. These are excellent techniques for use in neck and muscular abscesses.

Again, lidocaine under ultrasound guidance into the abscess wall for local anesthesia. Then under ultrasound guidance we will advance a 14 gauge angio catheter, needle and sheath system. Once it's in position, we'll withdraw the needle and then through the sheath, place a five French pigtail drainage catheter in a coaxial fashion, drain the abscess, lavage the abscess, and then connect it to a suction bulb mechanism.

Here we have two CT images from a young 12 month old child with two of three muscular abscesses demonstrated in the right shoulder. Here we see arrows on the two abscesses flanking the scapula. Here we see the width of one of these abscesses and you can see that the width is enough to allow a five French catheter to successfully be deployed for complete drainage.

Here's the abscess again, this is the 14 gauge Angie catheter sheath in place. The needle is pointing to the sheath without the needle in place. Now a quick illustration of how we perform this coaxial technique 14 gauge angio catheter. With the needle in place with the sheath in place and the needle removed, then we will advance the five French catheter. Note that the stiffening trocar is in place distally. We will then introduce that into the 14 gauge Angie catheter sheath. Once it is in position and the two tips of the catheters are meeting each other, then we will retract the stiffening trocar to allow the the pigtail drainage catheter to be flexible to exit in an a traumatic fashion. As it exit, it simply curls in the abscess cavity. Once it is curled, then we can withdraw the 14 gauge range of catheter sheath and match it hub to hub with the drainage catheter hub and then secure the catheter in place.

Here we see the needle and the sheath en entering the abscess cavity. Now the sheath without the needle in place in a coaxial fashion, you can see the five French drainage catheter being introduced into the 14 gauge Angie catheter sheath. Now the five French catheter with the tapered tip is exiting the 14 gauge Angie catheter sheath.

Here we have two of the three abscesses drained and now with drainage catheters in place we can lavage those abscesses and the child will respond very nicely in the neck. This technique is particularly advantageous. Here we see a right-sided large neck abscess sono graphically. We see this medium-sized abscess and here's the 14 gauge Angie catheter needle in sheath in place. Here's the five French catheter being introduced in a coaxial fashion into the abscess and here we have one abscess cavity being lavage here, the where the patient has two of these and it is not difficult to put two or more of these catheters in small abscesses that are multilocular.

Percutaneous Nephrostomy Placement

Now children provide unique challenges for percutaneous nephrostomy. Many times in the neonate, the neonates are the most challenging because of the relative stiff nature of the dysplastic kidneys that accompany hydronephrosis. In critical situation, this can be difficult to using a use a ser technique where we may lose access using a stepped approach where we are introducing multiple instruments into a system with secondary decompression. A single entry system gives us much greater advantage to work quickly and gain access and so again, the four French U sheath needle works very nicely or as an alternative, a an 18 gauge spinal needle works nicely. Both of those will accept an O three five inch amp plats wire and then we can dilate up and place a six French locking pigtail catheter into the neonatal hydro nephrotic collecting system.

Here we see a hydro nephrotic kidney. Here we see the needle introducing lidocaine into the perinephric tissues to the level of the renal capsule and then the arrow now is on the needle as it enters the collecting system in that KL EAL puncture site. With the coaxial system in place, this demonstrates the coaxial four French U sheath with an O three five inch G wire being positioned. Now we see the G wire in place in the renal collecting system over that guidewire that we can. We can then dil it up usually in the small children putting a six French catheter. In the micro premature infants we may need a five French catheter, but in larger children, usually eight French suffices. And then if we are in interventional radiology with fluoroscopic support, we can perform the antegrade nephros gram for further definition.

Not infrequently, we are called into the neonatal intensive care unit to perform percutaneous emergent cystostomy to allow for decompression of an obstructed renal system that is obstructed at the level of the urethra. This is most commonly seen in neonates with urethral atresia, severe posterior urethral valves and this is normally performed in the intensive care unit with sonographic guidance and then when the child is more stable, they can come to interventional radiology. For fluoroscopic studies, again, this is best performed with a single entry four French U sheath needle system. We would usually use the eight to nine megahertz Kline or phased array transducers. Again, the four French sheath needle will accept the O three five inch G wire and then we can dil it up and place a six inch locking pigtail drainage catheter.

Here we see this single step approach with a bladder and needle introducing lidocaine local anesthesia into the bladder wall. The needle indenting the bladder wall needle entering the bladder with a single puncture. Now with the sheath in place and the needle removed through that sheath, we can then place the guide wire into the bladder under ultrasound guidance and then place our drainage catheter over that with dilators as necessary.

Now we have the bladder catheter in place and then with that in place later on we can perform fluoroscopic studies. This was a patient who had a urethral rupture due to trauma and we had to perform the urgent percutaneous cystostomy.

Now remember that some children as in this small neonate with urethral stenosis with a high grade stenosis, the patient still has the ability to void, and so we must work quickly. Here we see the bladder with urine in it and the needle in place, but as we place the G wire, the patient then empties the bladder with voiding. Once we have the G wire in place, then we can successfully advance dilators and place a six French catheter into the bladder, and then in very small children a five French catheter is another alternative. Once the catheter is in place, then we can add saline to stand up the bladder to ensure that we are in excellent position.

Once the catheter is in place using an anterior supra pubic approach, then we can bring the patient down for fluoroscopic studies and as we see in these two frames in the bottom right frame, the urethra was successfully navigated with a guidewire and then a second catheter was in place using a transurethral approach, not uncommonly.

Cerebral Spinal Fluid Pseudotumor Management in Patients with Ventricular Peritoneal Shunts

Patients with ventricular peritoneal shunt catheters will develop failure of peritoneal resorption of the cerebral spinal fluid and develop a cerebral spinal fluid pseudocyst. We are now being asked to support the neurosurgical care of these patients with a drainage procedure and technique that we developed at Nationwide Children's Hospital. The surgeons have a need to assess the patient's for infection and see if they need to revise the shunt emergently. If there is no infection in the fluid, the neurosurgeon can then electively revise the shunt, and then our position is to help the neurosurgeons define urgency for surgery with ultrasound guided drainage of these fluid collections.

Again, similar story as before. Usually a five French coaxial needle in sheath system. It will be all that we need, or if you prefer, you can place an eight French pigtail drainage catheter for an in and out drainage procedure. We then will drain the pseudocyst and pull out the catheter, send the fluid for microbiological analysis. If there is sterile fluid and no bacteria with gram stain, then the patient can go home or they may even be sent home anyway and the neurosurgeon will follow up by telephone Note is made that less than 5% of these patients are ever infected and they can then be supported with non-urgent revision of their shunts.

Here we have a CT scan with a large CSF pseudo tumor with the ventricular peritoneal shunt catheter in the center. Same issue with ultrasound. The arrow is on the ventricular peritoneal shunt catheter. In the CSF fluid collection. Here we have the five French U sheath needle system in place. As the needle comes out, we see the side holes of the echogenic tip of the polyethylene sheath. That works very nicely and in this case we put an eight French drainage catheter and drained the fluid collection.

Here's the fluid collection before we begin drainage, now we see the drainage pigtail catheter within the decreasing fluid collection and then the arrow points to the eight French catheter, and then we see that the catheter is now within this very small remnant of the CSF collection before we re remove the drainage catheter.

So with ultrasound guidance using a a supra umbilical approach, we will then place the five french needle in sheath. Here we see the cerebral spinal fluid coming out, G wire in place, dilator in place, eight French catheter, and if we're dealing with a large fluid collection note is made of the long time that it takes to drain this fluid if we're using a simple syringe aspiration technique.

So then the question arises, how do you drain two to three liters quickly? Well, the answer is you connect your drainage catheter to an adapter system and use vacuum suction, and this will help you facilitate drainage again, either through simply a five French coaxial sheath needle and catheter system or an eight French pigtail catheter. Then we will connect that to wall suction.

Here we have the adapter connected to the catheter lu lock system and then using a blunt connector system that is then connected to the vacuum drainage system. The other end of the vacuum drainage tubing is handed off in a sterile fashion to the technologist who will then connect it to the drainage containers and begin vacuum suction or wall suction.

Here we see two liters of fluid drained from this patient after drainage completely of the fluid collection. Then we'll remove the catheters.

Unusual Situations: Foreign Body Removal

The last topic that we'll discuss is the rare situation in which we are asked to perform ultrasound guided foreign body removal and critical techniques that we utilize for this. First, the three frames on the right illustrate the hydrodissection using lidocaine with a 23 gauge needle. Here we see a wooden foreign body in place and the needles with the injection of lidocaine. The arrow here is indicating the lidocaine injection surrounding the foreign body and then two other errors demonstrating how the lidocaine will track as it de dissects the tissue away from the foreign body for removal.

Then we'll use tactile definition with forceps under ultrasound guidance and again, we can use the 23 gauge needle to contact the foreign body prior to introducing the forceps. Then with forceps, we can perform blunt dissection and if there's granulation tissue or scar tissue surrounding the foreign body, we can perform sharp dissection using a number 11 scalpel blade Under ultrasound guidance.

In our experience of now performing over 600 foreign body removals in 14 year timeframe, we have better than 98% successful removal of these soft tissue foreign bodies and occasionally intra tenderness and intraosseous foreign bodies with an average size of the incision of five millimeters. You can see that we remove these anywhere from the face, the orbit, the neck, the legs, the arms and the trunk, the two instruments that we use. First top, we see the Kelly forceps, the small Kelly forceps, and at the bottom, the alligator or Hartman forceps. Both of these are used with great advantage.

This is one of the two emergent situations that we've encountered, and again, with 600 cases, we've only had two times where we've had to come in emergently to remove the foreign body. This is a 13-year-old girl who has a fragment in her right chest wall that is causing pain. Her mother was cutting grass and she felt something hit her side and caused recurrent pain. On CT scan, you can see there is a metallic fragment that is in an intercostal position and every time she breathes she feels this irritate her abdomen and the surgeon was alarmed to see that this is precariously up against the liver edge and with bone windows we can see this is immediately adjacent to the liver capsule and so the surgeon asked if we could support the patient with ultrasound guided foreign body removal.

Here we see the subcutaneous tip of this large metallic piece of metal fragment and then looking more deeply, we see the tip of the metal fragment immediately adjacent to the liver edge, only two millimeters from the liver capsule, and here we see the frame with the needle in place for hydro dissection with lidocaine being administered surrounding the tip of the foreign body.

Now we have two arrows illustrating the forceps teeth being brought in to grasp the foreign body. As we remove the foreign body, we follow the foreign body and make sure that the distal end is coming out without any fragmentation, and then following the removal we will interrogate the field as well.

A second patient was development developmentally delayed patient with sepsis in the intensive care unit. If you notice, the intensivists were trying to gain vascular access using a left femoral approach and ran into difficulty and took this radiograph with a needle in place and they noticed that they had lost the guidewire and they had some difficulty placing the guidewire and needle access. As they removed the needle, they noticed that they had sheared the guidewire off and that it was embedded somewhere in the perivascular location. They called us to not only localize it but assist in ultrasound guided foreign body removal of this vascular G wire.

Here we see the arrow pointing to the G wire that is embedded in a subintimal location, so it entered through one wall, exited the lumen, and entered the subintimal location, and we can see in this frame how the the G wire is exiting the vascular lumen. The arrow now is on the forceps that are coming in under ultrasound guidance to grasp what is left of this guidewire with control and then remove it under sonographic guidance.

Conclusion

So in conclusion, hopefully this discussion illustrates some practical aspects of emergent and urgent utilization of ultrasound both in children and in young adults when interventional radiology care is required to support the patient, and in situations where sonography gives us unique and critical advantage for not only precise and elegant technical care, but also excellent care that supports the patient and allows for a very successful care team and successful care partnership for the patient's benefit.

Thank you.