My Patient Has A Swollen Leg PoCUS for DVT
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- Sandra Farmer
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1 My Patient Has A Swollen Leg PoCUS for DVT
2 Objectives Vascular Anatomy in the Lower Limb DVT Diagnostic Algorithm 2-Point PoCUS Technique Other causes of a Swollen Leg
3 Anatomy Lower Limb The Superficial Femoral Vein is a DEEP vein It accompanies the Femoral Artery Popliteal Vein has 3 main tributaries Anterior Tibial Tibio-peroneal Trunk Posterior Tibial Peroneal
4 Popliteal Vein Formed at lower border of Popliteus Ascends through Popliteal fossa to aperture in Adductor Magnus where it become the Femoral vein Initially lies superficial to then lateral to Popliteal artery Receives tributaries from Geniculate veins and Small Saphenous vein
5 Superficial Femoral Vein As the SFV ascends in thigh it is initially lateral to the Femoral artery, then superficial, then medial in the groin Joined by Deep Femoral Vein 4cm below Inguinal Ligament
6 DVT Clinical Clinical presentation of a DVT can be very non-specific (swelling, pain, warmth) Clinical features depends on site of venous occlusion Homan's sign = pain on passive dorsiflexion of the ankle is a non-specific sign (e.g calf strain) Many small DVTs are asymptomatic (e.g postop patients) Only 10-25% of patients with suspected DVT will subsequently be diagnosed with DVT
7 DVT Prognosis Below knee DVT s are rarely a source of clinically significant PE But, up to 1/3 of below knee DVT s can propagate above knee The incidence of PE with untreated above knee DVT is 29-50% And most PE s are first diagnosed at post mortem Scarvelis, D. et al. CMAJ 2006;175:
8 DVT Diagnosis Clinical Prediction Rule (e.g Wells) Risk factors, Symptoms and Signs Reliably stratifies into probability of DVT being Unlikely or Likely Algorithm Approach Clinical Prediction Rule D-Dimer Compression Venous Ultrasound +/- LMW Heparin
9 DVT Algorithm - Logic We do need to Diagnose and Treat above Knee DVT 2-Point CVU PoCUS is very sensitive(97%) for above Knee DVT We don t need to treat below knee DVT CVU PoCUS is not sensitive(73%) for below knee DVT anyway.. So no point looking below the knee. But 1/3 of below knee DVT will propagate above the knee However 2/3 don't propagate. But we can t rescan all the negatives (only 1-2% become +ve). So we need a way to choose a smaller group who we rescan
10 DVT Algorithm Scarvelis, D. et al. CMAJ 2006;175:
11 CVU - Criteria Experienced PoCUS clinician Understands the place of CVU within the algorithm Quality ultrasound equipment Ability to interpret Full Compression
12 CVU - Limitations Depth limitations / Patient habitus Pelvic veins are not visualised Operator error Calf DVTs not reliably visualised Acute on chronic DVT
13 2-Point PoCUS Protocol 2 point CVU at proximal thigh and popliteal fossa Performed in ED by ED Physicians Sensitivity similar to standard CVU = 96.8% (95%CI: % - Pomero et al Accuracy of emergency physician-performed ultrasonography in the diagnosis of deep-vein thrombosis: a systematic review and meta-analysis. Thromb Haemost Jan. 109(1):137-45)
14 2-Point PoCUS Protocol Tilt bed 20 reverse Trendelenburg Patient supine, Knees bent, Hips externally rotated Scan in transverse plane Place transducer distal to inguinal ligament at midinguinal point Identify superficial femoral vein (SFV), femoral artery and greater saphenous vein (GSV)
15 2-Point PoCUS Protocol Tilt bed 20 reverse Trendelenburg Left Leg Patient supine, Knees bent, Hips externally rotated Scan in transverse plane Place transducer distal to inguinal ligament at midinguinal point Identify superficial femoral vein (SFV), femoral artery and greater saphenous vein (GSV) Med Lat
16 2-Point PoCUS Protocol Assess from 2cm proximal and 2cm distal to the junction of SFV and GSV Look for visible thrombus Apply compressive pressure to SFV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of thigh to look for other cause of leg swelling (e.g muscle hematoma)
17 2-Point PoCUS Protocol Assess from 2cm proximal and 2cm distal to the junction of SFV and GSV Look for visible thrombus Apply compressive pressure to SFV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of thigh to look for other cause of leg swelling (e.g muscle hematoma)
18 2-Point PoCUS Protocol Assess from 2cm proximal and 2cm distal to the junction of SFV and GSV Look for visible thrombus Apply compressive pressure to SFV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of thigh to look for other cause of leg swelling (e.g muscle hematoma)
19 2-Point PoCUS Protocol Assess from 2cm proximal and 2cm distal to the junction of SFV and GSV Look for visible thrombus Apply compressive pressure to SFV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of thigh to look for other cause of leg swelling (e.g muscle hematoma)
20 2-Point PoCUS Protocol Turn patient onto side, etc Identify popliteal vein Assess 2cm distally to trifurcation Look for visible thrombus Apply compressive pressure to SFV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of calf to look for other cause of leg swelling (e.g Baker s cyst, muscle hematoma)
21 2-Point PoCUS Protocol Turn patient onto side Identify popliteal vein Assess 2cm distally to trifurcation Look for visible thrombus Apply compressive pressure to SFV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of calf to look for other cause of leg swelling (e.g Baker s cyst, muscle hematoma)
22 2-Point PoCUS Protocol Turn patient onto side Identify popliteal vein Assess 2cm distally to trifurcation Look for visible thrombus Apply compressive pressure to PV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of calf to look for other cause of leg swelling (e.g Baker s cyst, muscle hematoma)
23 2-Point PoCUS Protocol Turn patient onto side Identify popliteal vein Assess 2cm distally to trifurcation Look for visible thrombus Apply compressive pressure to PV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of calf to look for other cause of leg swelling (e.g Baker s cyst, muscle hematoma)
24 2-Point PoCUS Protocol Turn patient onto side Identify popliteal vein Assess 2cm distally to trifurcation Look for visible thrombus Apply compressive pressure to PV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of calf to look for other cause of leg swelling (e.g Baker s cyst, muscle hematoma)
25 2-Point PoCUS Protocol Turn patient onto side Identify popliteal vein Assess 2cm distally to trifurcation Look for visible thrombus Apply compressive pressure to PV If resolution suboptimal consider colour flow to help delineate vessel If negative,quick sweep of calf to look for other cause of leg swelling (e.g Baker s cyst, muscle hematoma)
26 Proximal DVT Normal DVT
27 Proximal DVT Normal DVT
28 Proximal DVT
29 Proximal DVT
30 Popliteal DVT Normal DVT
31 Popliteal DVT Normal DVT
32 Popliteal DVT
33 Popliteal DVT
34 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst 50yr old female, recent long haul flight returning from holiday in Cuba - Swollen Leg Popliteal Aneurysm
35 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst 50yr old female, recent long haul flight returning from holiday in Cuba - Swollen Leg Popliteal Aneurysm
36 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm 84yr post op Total Hip Replacement - Swollen Leg
37 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm 84yr post op Total Hip Replacement - Swollen Leg
38 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal 60yr 3 days immobility following fall - Swollen Leg Aneurysm
39 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal 60yr 3 days immobility following fall - Swollen Leg Aneurysm
40 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal 70yr Pain in back of Knee - Swollen Calf Aneurysm
41 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal 70yr Pain in back of Knee - Swollen Calf Aneurysm
42 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm 70yr Pain in back of Knee - Swollen Calf
43 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm 70yr Pain in back of Knee - Swollen Calf
44 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm 70yr Pain in back of Knee - Swollen Calf
45 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm 70yr Pain in back of Knee - Swollen Calf
46 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm 70yr Pain in back of Knee - Swollen Calf
47 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm Axillary Vein 70yr Treated for Cellulitis 5 days - Swollen Arm
48 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm Axillary Vein 70yr Treated for Cellulitis 5 days - Swollen Arm
49 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm Brachial Vein 70yr Treated for Cellulitis 5 days - Swollen Arm
50 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm Brachial Vein 70yr Treated for Cellulitis 5 days - Swollen Arm
51 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm Brachial Vein 70yr Treated for Cellulitis 5 days - Swollen Arm
52 Differential Diagnosis DVT Cellulitis Subcutaneous Muscle Bakers Cyst Popliteal Aneurysm Brachial Vein 70yr Treated for Cellulitis 5 days - Swollen Arm
53 Questions?
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