Emergency department point-of-care ultrasound for upper extremity deep venous thrombosis ED POCUS for upper extremity DVT

Abstract

Background Upper extremity deep vein thrombosis (UEDVT) is an uncommon disease but has to be carefully considered in patients with isolated unilateral upper limb swelling due to its potential to cause devastating complications and sequelae such as pulmonary embolism and septic thrombophlebitis. Given the extreme rarity of this condition, it is not surprising that point-of-care ultrasonographic evaluation of the upper limb for deep venous thrombosis is hardly ever performed in the emergency department. This case report serves to highlight how point-of-care ultrasonographic evaluation of the upper extremity venous system could be incorporated as a tool in the diagnostic armamentarium of the emergency physician. Case presentation A 51-year-old Chinese gentleman presented to the emergency department with a 1-day duration of progressive right upper extremity swelling and pain. On examination, his hemodynamic parameters were stable with no tachycardia. He was noted to have a hyperaemic and grossly swollen but non-tender right upper limb. Distal pulses remained strong. Point-of-care ultrasonography of his right upper limb venous system with Doppler colour flow and single-point augmentation with the arm squeeze manoeuvre immediately confirmed the diagnosis of right upper extremity deep venous thrombosis, which in turn permitted anticoagulation to be instituted promptly whilst in the emergency department. Conclusion The use of point-of-care ultrasonography of the upper limb venous system can prove invaluable as a rapid, non-invasive technique to facilitate expedient diagnosis of and early intervention for UEDVT in the emergency department.

From compression to diagnosis: identification of superior vena cava syndrome using point-of-care ultrasound in the emergency department

“…A high frequency linear array transducer should be used with the vascular preset. As some of the upper limb deep veins are difficult to compress, the examination may need to rely on finding the echogenic clot and lack of spontaneous or augmented flow using colour Doppler [ 11 ]. The transducer should be placed in a transverse position over the sternocleidomastoid muscle to evaluate the IJ vein.…”

Diagnosis of Internal Jugular Vein Septic Thrombophlebitis by Point-of-Care Ultrasound

“…Limited case reports have shown ability to detect upper extremity and IJV thrombi with POCUS. 3,4,[33][34][35][36] Only a single report of 3 patients involved the use of POCUS in the PED. 33 To our knowledge, this is the first report of IJV septic thrombophlebitis diagnosed by POCUS in the PED.…”

“…There is a paucity of data in the pediatric population, although Watkins et al 32 showed 100% agreement between radiology and POCUS evaluation of lower extremity DVT in a small pediatric population. Limited case reports have shown ability to detect upper extremity and IJV thrombi with POCUS 3,4,33–36 . Only a single report of 3 patients involved the use of POCUS in the PED 33 .…”

New applications of perioperative POCUS: beyond the Big 4

“…POCUS techniques come with a false-negative rate of 4% when compared with radiology-performed exams, and POCUS algorithms may miss distal DVTs that have been implicated in a higher proportion of PE 15. The use of POCUS to identify upper extremity DVT is less well described, limited to case reports without evidence of sensitivity or specificity 24. This limitation is particularly concerning when examining inpatients and the critically ill as upper extremity DVT is much more likely in the setting of upper extremity intravenous catheters, cancer, and severe illness 18…”

“…15 The use of POCUS to identify upper extremity DVT is less well described, limited to case reports without evidence of sensitivity or specificity. 24 This limitation is particularly concerning when examining inpatients and the critically ill as upper extremity DVT is much more likely in the setting of upper extremity intravenous catheters, cancer, and severe illness. 18…”