The tides have shifted. The days of poking a finger into a mass, declaring it a fluctuant abscess and opening it are over. With point of care ultrasound widely available, it makes sense to scan the area you are planning to cut into. You never know what you may find.
This week, in the Journal of Ultrasound in Medicine, Blaivas and Adhikari published their case series of Unexpected Findings on Point-of-Care Superficial Ultrasound Imaging Before Incision and Drainage. They recorded a total of six cases. A wrist mass clinically consistent with abscess found to contain arterial flow on ultrasound that was ultimately diagnosed as a liposarcoma. A couple of cases where upper extremity abscesses were unroofed rather than incised due to proximity to vascular structures. An abdominal wall abscess that turned out to be an incarcerated hernia. A femoral artery pseudoaneurysm, and a solid mass thought to be an atypical bartholin’s cyst eventually diagnosed as labial cancer
These six cases are a clarion call.
We have all seen similar instances of unfortunate misses and ultrasound saves when scalpels are involved. The abdominal abscess that is drained of succus rather than pus. The fluctuant abscess that opens to blood at arterial pressure. The Chest X-Ray with fat arrows pointing out the obvious pneumothorax that turns out to be a skin fold. Many of us use ultrasound to differentiate cellulitis from abscess, but ultrasound can save the day in so many varied ways.
The hand that holds the scalpel ought to have just put down a probe.
This publication is not the first report of an unexpected ultrasound finding changing management, but if you are interested in saving your patient a trip to the OR to repair damage you have done, consider taking a quick look with ultrasound. The hand that holds the scalpel ought to have just put down a probe.