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Pt-Bilat LE pain/swelling 5 days.Prior hx of unprovoked DVT/PE years ago but off meds due to insurance. See thread. POCUS DVT #POCUS #IMPOCUS #FOAMed #FOAMus #MedEd #FOAMcc @ACEP_EUS @medpedshosp @cianmcdermott @jminardi21 @grepmeded @siddharth_dugar @msiuba @NephroP @SonoStache
What POCUS DVT protocol to use? 2-point or 3-point or extended? With or without Doppler? Meta-analysis showed good performance of 2 and 3 point POCUS but need to understand POCUS compression limitations if only compression used: https://pubmed.ncbi.nlm.nih.gov/31145304/?from_term=POCUS+dvt&from_pos=3
Adhikari and colleague article showed 6.3% false neg rate due to prox isolated DVT with 2-point compression. Limitations of POCUS prox compression DVT exam go beyond just missing isolated/focal DVT. https://pubmed.ncbi.nlm.nih.gov/25465473/
With Bilat symptoms need to think about proximal obstruction (IVC/EIV) or Bilat DVT.Potential to miss prox cause if Doppler not used to assess waveform.If study neg with bilateral symptoms, think proximal. Case of EIV DVT-Doppler used: @jminardi21 https://pubmed.ncbi.nlm.nih.gov/29849283/?from_term=POCUS+dvt&from_pos=7
This patient had no thrombus seen in bilateral proximal compression scan from CFV to POP V (not 2 or 3-point). Rt proximal shown. Has spont echo contrast but no DVT. Do you stop here and pursue other diagnoses? Answer-No!
Doppler waveform obtained in R/L CFV. Showed monophasic waveform concerning for proximal obstruction (see image). There is loss of respirophasicity. Difficulty scanning EIV due to bowel gas but went to IVC next.
IVC TRV sweep-proximal to distal. Note IVC thrombus. Key point with POCUS compression exam: If negative but high suspicion or concern for proximal obstruction, get Doppler waveform and further imaging.
Great review article on IVC thrombus. Pt worked up-no IVC congenital abnormality or malignancy. Felt to be due to thrombophilia. Since thrombus acute underwent CDT https://interventions.onlinejacc.org/content/jint/9/7/629.full.pdf
One more article. This one on importance of monophasic waveform in CFV.
