Point-of-Care Ultrasound in the Inpatient Setting: A Tale of Four Patients

Renee K. Dversdal, MD; KevinM. Piro, MD; Charles M. LoPresti, MD; Noelle M. Northcutt, MD; Daniel J. Schnobrich, MD

Disclosures

South Med J. 2018;111(7):382-388. 

In This Article

Case 2

A 55-year-old man with a history of type 2 diabetes mellitus complicated by recurrent lower extremity ulcers and recently diagnosed non-small-cell lung adenocarcinoma presented with right lower leg edema, nonpurulent erythema, and tenderness. A review of systems was negative except for recent worsening pain in a nonhealing ulcer over the lateral malleolus. In the emergency department he was noted to have a leukocytosis, was started on vancomycin and piperacillin/tazobactam for presumptive cellulitis, and admitted. The morning after admission there was no clinical improvement. Given his new 2+ pitting edema and malignancy, lower extremity deep vein thrombosis (DVT) needed to be excluded. Using a handheld US machine present on rounds, we performed a DVT examination of the right leg.

Literature Review and Discussion

POCUS examination for lower extremity DVT provides a timely assessment for an urgent medical diagnosis. Complete vein compression rules out DVT (Figure 3). It also allows for quick decision making regarding anticoagulation needs. Research shows that the DVT examination can be performed reliably outside of the radiology department. In addition, a simple compression-only examination is accurate for the detection of DVT.[22–27] A systematic review and meta-analysis looked at 16 studies, with a total of 2379 patients examined. When compared with formal radiology DVT examinations, nonradiologists had a mean sensitivity of 96.1% (95% confidence interval [CI] 90.6–98.5) and a mean specificity of 96.8% (95% CI 94.6–98.1).[28] Although many nonradiologic studies are completed by emergency physicians, outpatient general practitioners also accurately detect DVT (95.8%; 95% CI 94.7–97.0), with a sensitivity of 90.0% (95% CI 88.2–91.8) and a specificity of 97.1% (95% CI 96.2–98.1).[29] The cause of the lower sensitivity in this study was not apparent. It also is not yet clear which test characteristics are more likely to occur in hospitalized patients, although the authors are aware of one unpublished manuscript describing DVT detection in noncritically ill hospital medicine patients that more closely resembles emergency medicine figures.

Figure 3.

Complete, normal common femoral vein compression.

US Findings and Case Resolution

A two-zone examination was performed, obtaining images of the right common femoral vein, branching points through the proximal femoral vein (zone 1), and popliteal vein (zone 2). The common femoral vein did not fully compress despite applied pressure (Figure 4). The diagnosis of occlusive DVT in the common and proximal femoral veins was made within 5 minutes, and shortly thereafter the patient was started on anticoagulation with antibiotic cessation.

Figure 4.

Lack of complete vein compression despite artery on left starting to compress, ruling in deep vein thrombosis. Corresponding ultrasound clips can be viewed at http://links.lww.com/SMJ/A107.

This case serves as an example of how POCUS can be used to quickly rule in the presence of DVT. Compared with formal US in the radiology department, this allows for a much quicker diagnosis and shortens the time to critical management.[30]

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