Bedside Sono for DVT: Will it ever see the light of day?


    Bedside Sono for DVT: Will it ever see the light of day?

    Bedside sono for DVT: Ready for primetime?

    You got a patient with an enlarged, red, angry leg. It screams sono me for DVT! It is midnight and radiology tells you it cannot be done until the morning. Can YOU sono the patient?

    Technically yes…we have an ultrasound and bedside sono’s for DVTs are easy right? 2-point compression-meaning compression of the common femoral and popliteal veins alone is all we need. According to Jang et al 2010 2-point compression had a S&S of 100%/99% respectively when compared with radiology department studies. That was amongst ED physicians at various levels of training who had received a 10-min tutorial on bedside sonos.


    ALiEM PV Card: Focused Deep Vein Thrombosis (DVT) Ultrasound No DVT


    ALiEM PV Card: Focused Deep Vein Thrombosis (DVT) Ultrasound No DVT


    ALiEM PV Card: Focused Deep Vein Thrombosis (DVT) Ultrasound DVT in femoral vein

    More recently the literature such as Adhikari et al 2015 shows we may miss approx 6% of DVTs w/ the 2-point approach. Primarily in the femoral vein and deep femoral vein.


    Adhikari et al 2015

    As Mike, Mike, and Matt point out on their Ultrasound Podcast non-ambulatory patients are more likely to have occult DVTs (segmental or incompletely occlusive) and in areas not captured by 2 point compression. Also in general it is very common to have DVTs at venous confluences such as the saphenofemoral branch which may be missed in 2-point compression.

    According to a conversation with Adhikari he instructs evaluation at the following areas:  (1) common femoral vein (2) saphenofemoral junction (3) deep femoral vein (4) popliteal and its branching points.

    See Ultrasound Podcast for how to perform Whole Leg US



    • Make sure you’re checking for DVTs at branch points such as saphenofemoral branch point
    • In non-ambulatory patients be weary of DVTs in segmental areas or areas not captured on 2-point bedside sono
    • Of course your pretest probability will ultimately factor into your management for each patient



    • Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med. 2010 Dec;56(6):601-10.
    • Adhikari, S., Zeger, W., Thom, C., & Fields, J. M. (2015). Isolated deep venous thrombosis: implications for 2-point compression ultrasonography of the lower extremity. Annals of emergency medicine, 66(3), 262-266.
    • Lin, M. PV Card: Focused Deep Vein Thrombosis (DVT) Ultrasound.
    • Dawson, M., Mallin, M., & Stone, M. DVT Ultrasound Controversy! @bedsidesono discusses why 2 point compression not good enough #foamed
    • Dawson, M., Mallin, M., & Stone, M. DVT Ultrasound demonstration with @bedsidesono.  The whole upper leg approach.  #FOAMED
    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • renal handling of water

      If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. AndRead more

    • acute acidemia physiology

      As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all knowRead more

    • renal handling of potassium

      the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then askRead more

    • bicarbonate revisited

      Previous post reviewed the safety of balanced crystalloids in hyper K. But what was up with serum bicarbonate decreasing with saline administration? This post introduces a new way of looking at the anion gap to possiblyRead more

    • hyperkalemia and balanced crystalloids

      Is it safe to give LR or plasmalyte to a hyperkalemic patient (these balanced crystalloids have 4-5 mEq/L K as opposed to 0 mEq/L K in normal saline)? Postponing the discussion of renal handling of potassium toRead more

    • hyperkalemia physiology

      You’ll likely encounter hyperkalemia on your next Resus / Cardiac shift, and you’ll instinctively treat it. But take a moment to review the fascinating physiology behind the “cocktail”! First, consider how K+ is buffered byRead more

    • Slow down your tachycardia (but not really)

      You’re sitting in resus bemoaning the departure of your most beloved attending when suddenly a patient wheels in without warning. The patient looks relatively stable but the triage RN tells you her heart rate wasRead more

    • Otitis externa: use the ear wick!

      Acute otitis externa (AOE) is a common complaint seen in pediatric as well as adult emergency departments. AOE is typically not accompanied by acute otitis media, although concurrent cases are possible. Also called “swimmer’s ear”Read more