HPI: 90 yo female presenting for worsening shortness of breath and tachycardia x 3 days and right leg pain x 2 weeks with difficulty ambulating.
POCUS showed:
ECHO A4C view (see video): note the size of the RV appears larger than the LV. This is a sign of right heart strain and in the appropriate setting (such as this one) can be concerning for a pulmonary embolism!
Compression views of the common femoral vein (CFV), femoral vein (FV), and popliteal vein (PV). See the echogenic material inside the popliteal vein which is suggestive of a DVT. Remember that during the acute phase of a DVT (<14 days), the clot may appear isoechoic to the blood inside the vein so you may not see this echogenic material and should rely more on your compression exam.
Review on how to do DVT US:
Linear probe
Patient in frog leg position
4 main areas to view
Common femoral vein (CFV)-saphenous vein junction (SFV)
Clot noted in the SFV within 3 cm to the junction is treated as a DVT. More distally, if there is 5 cm worth of clot noted in the SFV it is also treated as a DVT.
CFV branching into [superficial] femoral vein and deep femoral vein
Mid/distal femoral vein
Popliteal vein
Remember the popliteal vein is on top of the popliteal artery (pop on top!)
Tips:
You often have to go much higher in the groin than you think to find the CFV-SFV junction
Compression testing of the deep veins should not compress the artery (if it is, you’re pressing too hard and can miss subtle DVTs)
Deep veins are paired with arteries so identify your landmarks to ensure you are looking at the correct vessels
Use your non-scanning hand to help with compression of deeper veins by supporting the other side of the patient’s leg
Case conclusion: Patient with elevated troponin and BNP. CTA significant for bilateral PE’s. Labs and ECHO findings consistent with submassive PE. Patient started on heparin drip and admitted to the floor!
Happy scanning!
The US Team