POCUS – Soft Tissue Ultrasound – Soft Tissue Edema

September 9, 2019

hi and welcome to a point-of-care ultrasound geek my name is Jared marks I’m an emergency physician an ultrasound director for a residency program and I’ve been teaching ultrasound to people residents for several years now I find soft tissue ultrasound highly useful in the IDI I have a provider say to me often that they can tell if there’s an abscess or cellulitis or if it’s cellulitis or other injuries there without ultrasound I tell you that you know studies are showing that not to be true that it’s we can definitely detail better what’s going on below the skin by using soft tissue ultrasound and the management often changes once ultrasound is used also there’s some studies to show or that we might have more successful drainage of abscesses when present so I would encourage you 100% of the time whether you think it’s cellulitis or abscess to do ultrasound as it might change your management and over the next few videos hopefully this will help you to understand how to use soft tissue ultrasound in the care of your patients in this video we’re going to talk simply about edema that’s present edema is typically what you’re gonna see when only cellulitis is present please do not ultrasound the breast I don’t think that’s within the purview of point of care ultrasound I think that is requires expertise beyond that that we have with point of care ultrasound I would tell you that even amongst radiologists that there are many that do not read breast tissue ultrasound and maybe even your breast surgeons do not the reason why is because in a breast cancer can appear much like an abscess it can get a discharge with it it can create an area that looks like an abscess and I would not I would hate to have you in size into breast cancer and not an abscess so please do not ultrasound the breast tissue leave that up to your experts I think that’s without is beyond the expertise of point of care ultrasound when we look at this who are we going to perform this on we’re going to be performing this on people with pain redness swelling warmth an area and possible even systemic fever it I would encourage you again 100% of the time Yuna if you think it’s a cellulitis to take a look with an ultrasound just drag along the area and make sure there’s no abscess that needs to be drained there’s an abscess present it’s unlikely to get better with just antibiotics alone and I would encourage you to use ultrasound to determine if that’s present or not here we see the back of a patient’s leg that came in and was having some pain in this area as you can tell there’s mild redness in the area it was slightly warm to the touch and she had pain but no fever and no significant swelling that we could see externally however we’ll see her ultrasound throughout the remainder of this video so when we look at this image here we can see what the layers of tissue should look like we have our epidermis at the very top this is a very thin layer often you’re not going to appreciate much difference as you can see there’s a slight hyper core Cline the adipose tissue is typically what we’re going to focus on that’s gonna be sitting above the fascial layer that’s where the typical you’re typically in the see your edema your abscess hematoma those type of things it’s not to say you can’t have them in the muscle and you should pay attention to your muscle but that’s typically where just a cellulitis an abscess will sit and that’s typically what we’re going to take care of at the bedside and not in the heart if we take that same area of the body and just rotate the probe into long access here we can see along here there’s a facial plane here’s our adipose tissue or fat layer again here’s our striations through our muscle here’s another fashion layer what’s a muscle below that once again we’re gonna look in this main area now if you notice when we start teaching this in this video I’ve shown you normal I had 100% of the time recommend that you look at the normal site first so patients typically have a contralateral extremity that we can image if you’re on the trunk and can’t go all the way to the contralateral side then a view adjacent tissue often where I see mistakes is when people only image what they think is the pathology and they misidentified normal tissue or a variant as abnormal so I’d encourage you to 100% of the time look at your normal site first and then continue on to your affected site so what we’re talking about today in this video is soft tissue edema this is what we’ll typically see in a cellulitis so unfortunately edema due to cellulitis looks exactly like edema due to heart failure and looks like edema due to fluid overload edema in the soft tissues looks the same regardless of the pathology and so you got to be very careful about this here’s the two areas we’re gonna look at that we’re gonna have loss of soft tissue differentiation and it will be typically hyper coke in the region we’re gonna look at a normal video here first we can see here a facial layer and here’s our adipose layer and that’s what we’re gonna look we can see some hyper code structures throughout that but it doesn’t all look the same then we have muscle down below I’m gonna rotate our probe into a short access again here’s our facial layer here our adipose tissue layer epidermis is up here we’re gonna look at our muscle here we don’t see any pathology or any issues there and then once again we can see that there’s some differentiation there some hyper culligan i bought coke areas throughout the post tissue now if we compare that to and the affected area in this patient we see the facial layer again and above that we can appreciate that there’s loss of soft tissue differentiation and we don’t see those same hyper Cokin hypoechoic structures it’s just a pipe bar a coke everywhere if we continue to image the area we can see over here maybe some anechoic structures we’d want to pay attention to that to make sure it’s not an abscess or if it’s a vessel this may be what we call cobblestone a developing we’ll look at that in a later video same thing here this is just going down for the leg we see some fluid tracking through here this does not look like an abscess which we’ll be able to do in a later video so here’s our hyper cork structure the big thing we’re paying attention to is we have loss of tissue differentiation and it’s hyper echoing here’s an example of a vessel tracking through there notice how it’s well circumscribed we could put pressure on it like we do when we verify veins for vascular access or for DVT and we could verify that it’s best you can throw a color or power Doppler over it or pulse wave Doppler and you can see the flow through them and lastly we have that structure rotated out and it long access once again the soft tissue are the fashion layers here we have loss of soft tissue differentiation and it’s hyper colored so hopefully reviewing these findings is useful to you remember that these are nonspecific and can relate to any type of edema not just cellulitis but other things that lead to edema in legs or in the soft tissues however hopefully this will help you to in the right clinical scenario assure that there’s no abscess present and that there is it is only cellulitis or vice versa thanks for watching I hope you found this useful in the use of soft tissue ultrasound if you have any questions about this or alter other point of care ultrasound applications feel free to email me a pocus geek at

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