Duplex Ultrasound in the Emergency Department for the Diagnostic Management of Clinically Suspected Deep Vein Thrombosis

Magazzini, Simone; Vanni, Simone; Toccafondi, Simone; Paladini, Barbara; Zanobetti, Maurizio; Giannazzo, Giuseppe; Federico, Roberto; Grifoni, Stefano

doi:10.1111/j.1553-2712.2007.tb01776.x

Cited by 30 publications

(29 citation statements)

References 17 publications

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“…'Proximal' thrombosis in or above the popliteal vein (PV) affects 76-88% of symptomatic patients and causes serious sequelae in approximately 50% of untreated cases. [7][8][9][10][11][12][13] 'Distal' thrombosis isolated below the PV occurs in the remainder and rarely produces clinically significant pulmonary embolism. [7][8][9][10][14][15][16][17][18] Proximal LEDVT almost invariably exists at the common femoral vein (CFV) or PV, so US of these vessels detects virtually all LEDVT requiring anticoagulation.…”

Section: Introductionmentioning

confidence: 99%

“…[7][8][9][10][11][12][13] 'Distal' thrombosis isolated below the PV occurs in the remainder and rarely produces clinically significant pulmonary embolism. [7][8][9][10][14][15][16][17][18] Proximal LEDVT almost invariably exists at the common femoral vein (CFV) or PV, so US of these vessels detects virtually all LEDVT requiring anticoagulation. 7,10,[19][20][21][22] Repeating this 'two-point' examination also identifies the 10-25% of distal thromboses that propagate proximally.…”

Section: Introductionmentioning

confidence: 99%

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Sensitivity and specificity of three‐point compression ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis

Crowhurst

Dunn

2013

Emerg Medicine Australasia

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Sensitivity and specificity of three‐point compression ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis

Crowhurst

Dunn

2013

Emerg Medicine Australasia

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“…POCUS may yield high negative predictive value for DVT evaluation, avoid unnecessary anticoagulant treatment, and may be performed when radiology studies are not available with good accuracy [62, 63]. …”

Section: Diagnostic Applications Of Ultrasoundmentioning

confidence: 99%

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

et al. 2016

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The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed “how to” and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

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“…Based on conservative literature estimates and our own experience, and assuming a total enrollment of 140 patients, we estimated that at least 100 (70%) would be DVT negative . Assuming LC US to be at least 90% specific, the exact 95% confidence band around this point estimate would be relatively narrow at ±6%. Assuming the D‐dimer to be only 70% specific, we would have over 80% power at a two‐sided alpha of 0.05 to detect a specificity improvement of 20% using McNemar's test.…”

Section: Methodsmentioning

confidence: 99%

“…Portable US at the bedside by EPs has become routine for a number of conditions, usually as a component of the overall diagnostic approach rather than a stand‐alone diagnostic test. An abbreviated US examination of the lower extremity has been proposed for the bedside diagnosis of DVT by EPs, a technique commonly referred to as limited‐compression (LC) US …”

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confidence: 99%

Estimated Effect of an Integrated Approach to Suspected Deep Venous Thrombosis Using Limited‐compression Ultrasound

Poley

Newbigging

Sivilotti

2014

Academic Emergency Medicine

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Objectives Deep vein thrombosis (DVT) is both common and serious, yet the desire to never miss the diagnosis, coupled with the low specificity of D‐dimer testing, results in high imaging rates, return visits, and empirical anticoagulation. The objective of this study was to evaluate a new approach incorporating bedside limited‐compression ultrasound (LC US) by emergency physicians (EPs) into the workup strategy for DVT. Methods This was a cross‐sectional observational study of emergency department (ED) patients with suspected DVT. Patients on anticoagulants; those with chronic DVT, leg cast, or amputation; or when the results of comprehensive imaging were already known were excluded. All patients were treated in the usual fashion based on the protocol in use at the center, including comprehensive imaging based on the modified Wells score and serum D‐dimer testing. Seventeen physicians were trained and performed LC US in all subjects. The authors identified a priori an alternate workup strategy in which DVT would be ruled out in “DVT unlikely” (Wells score < 2) patients if the LC US was negative and in “DVT likely” (Wells score ≥ 2) patients if both the LC US and the D‐dimer were negative. The criterion standard was based on comprehensive imaging interpreted by radiologists blinded to LC US findings and by structured medical record review at 6 months in patients without comprehensive imaging. Results A total of 227 patients were enrolled (47% DVT likely), of whom 24 had DVT. The LC US was positive in 27 cases (21 actually DVT positive), indeterminate in 28 (one DVT positive), and negative in 172 (two DVT positive). Of 130 patients deemed DVT negative by the new strategy, one had confirmed DVT (miss rate = 0.8%; 95% confidence interval [CI] = 0.1% to 4.0%), but this patient had been misclassified by the treating physician as low risk by Wells criteria. The stand‐alone sensitivity and specificity of LC US were 91% (95% CI = 70% to 98%) and 97% (95% CI = 92% to 99%), respectively. Incorporating LC US into the diagnostic approach would have reduced the rate of comprehensive imaging from 70% to 43%, D‐dimer testing from 100% to 33%, and the mean time to diagnostic certainty by 5.0 hours and avoided 24 (11%) return visits for imaging and 10 (4.4%) cases of unnecessary anticoagulation. In 19% of cases, the treating and scanning physician disagreed whether the patient was DVT likely or DVT unlikely based on Wells score (κ = 0.62; 95% CI = 0.48 to 0.77). Conclusions Limited‐compression US holds promise as one component of the diagnostic approach to DVT, but should not be used as a stand‐alone test due to imperfect sensitivity. Tradeoffs in diagnostic efficiency for the sake of perfect sensitivity remain a difficult issue collectively in emergency medicine (EM), but need to be scrutinized carefully in light of the costs of overinvestigation, delays in diagnosis, and risks of empirical anticoagulation.

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Duplex Ultrasound in the Emergency Department for the Diagnostic Management of Clinically Suspected Deep Vein Thrombosis

Abstract: EDUS examination yielded a high negative predictive value and good positive predictive value, allowing rapid discharge and avoiding improper anticoagulant treatment.

Cited by 30 publications

References 17 publications

Sensitivity and specificity of three‐point compression ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis

Sensitivity and specificity of three‐point compression ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

Estimated Effect of an Integrated Approach to Suspected Deep Venous Thrombosis Using Limited‐compression Ultrasound

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