How To: Deep Vein Thrombosis
How To: Deep Vein Thrombosis
<p begin="00:00:15.260" end="00:00:17.144" style="s2">an ultrasound examination in the E.D.</p>
<p begin="00:00:17.144" end="00:00:19.994" style="s2">to determine if a patient<br />has deep vein thrombosis,</p>
<p begin="00:00:19.994" end="00:00:22.547" style="s2">and this is a well established<br />practice of ultrasound.</p>
<p begin="00:00:22.547" end="00:00:24.304" style="s2">We're gonna do a modified version of that</p>
<p begin="00:00:24.304" end="00:00:26.147" style="s2">for the E.D. exam though.</p>
<p begin="00:00:26.147" end="00:00:29.837" style="s2">To set up for this<br />examination you want to tilt</p>
<p begin="00:00:29.837" end="00:00:32.652" style="s2">the gurney, so that you're<br />in a reverse trandelenburg.</p>
<p begin="00:00:32.652" end="00:00:35.080" style="s2">So this encourages venous<br />extension in the leg,</p>
<p begin="00:00:35.080" end="00:00:38.978" style="s2">so it's easier to visualize<br />the veins with ultrasound.</p>
<p begin="00:00:38.978" end="00:00:42.416" style="s2">We're going to use a linear<br />transducer for this examination,</p>
<p begin="00:00:42.416" end="00:00:44.406" style="s2">and the views that we do for this exam</p>
<p begin="00:00:44.406" end="00:00:47.209" style="s2">will just be in a<br />transverse orientation only.</p>
<p begin="00:00:47.209" end="00:00:49.688" style="s2">So when you're setting<br />up for this examination</p>
<p begin="00:00:49.688" end="00:00:53.122" style="s2">make sure the orientation<br />marker again is to the right.</p>
<p begin="00:00:53.122" end="00:00:55.774" style="s2">For this examination<br />technique we're gonna use</p>
<p begin="00:00:55.774" end="00:00:57.800" style="s2">a compression technique where we just</p>
<p begin="00:00:57.800" end="00:01:02.501" style="s2">slightly compress the vein<br />with some downward motion.</p>
<p begin="00:01:02.501" end="00:01:05.482" style="s2">When you set up the exam on the system,</p>
<p begin="00:01:05.482" end="00:01:07.245" style="s2">just select the exam key,</p>
<p begin="00:01:07.245" end="00:01:10.831" style="s2">then from your menu select<br />the venous exam type,</p>
<p begin="00:01:10.831" end="00:01:12.632" style="s2">and hit select.</p>
<p begin="00:01:12.632" end="00:01:14.685" style="s2">When you do this you're<br />optimizing the system,</p>
<p begin="00:01:14.685" end="00:01:16.671" style="s2">so it's automatically configured</p>
<p begin="00:01:16.671" end="00:01:19.838" style="s2">for your best resolution of the veins.</p>
<p begin="00:01:22.729" end="00:01:24.884" style="s2">We're gonna use a little<br />bit of ultrasound gel,</p>
<p begin="00:01:24.884" end="00:01:26.990" style="s2">and we're gonna assess two areas.</p>
<p begin="00:01:26.990" end="00:01:29.263" style="s2">The femoral area and the popliteal area.</p>
<p begin="00:01:29.263" end="00:01:32.430" style="s2">I'm gonna start with the femoral area.</p>
<p begin="00:01:33.309" end="00:01:35.914" style="s2">We're going to place the<br />ultrasound transducer</p>
<p begin="00:01:35.914" end="00:01:38.222" style="s2">at the inguinal crease...</p>
<p begin="00:01:38.222" end="00:01:39.972" style="s2">in a transverse view.</p>
<p begin="00:01:41.248" end="00:01:44.044" style="s2">When I do this, immediately<br />below the transducer and the</p>
<p begin="00:01:44.044" end="00:01:47.832" style="s2">ultrasound image I'm going to<br />see two anechoic structures.</p>
<p begin="00:01:47.832" end="00:01:49.177" style="s2">The one that's gonna be more</p>
<p begin="00:01:49.177" end="00:01:51.533" style="s2">medial is the common femoral vein.</p>
<p begin="00:01:51.533" end="00:01:55.265" style="s2">The one that's more lateral<br />is the common femoral artery.</p>
<p begin="00:01:55.265" end="00:01:57.690" style="s2">The way I can landmark<br />this is by looking for</p>
<p begin="00:01:57.690" end="00:02:00.224" style="s2">the junction with the saphenous vein,</p>
<p begin="00:02:00.224" end="00:02:01.794" style="s2">or the long saphenous vein.</p>
<p begin="00:02:01.794" end="00:02:03.795" style="s2">And we see this emptying into the</p>
<p begin="00:02:03.795" end="00:02:06.486" style="s2">anterior aspect of the<br />common femoral vein.</p>
<p begin="00:02:06.486" end="00:02:09.639" style="s2">And in this image we actually see the</p>
<p begin="00:02:09.639" end="00:02:12.172" style="s2">venous valves separating</p>
<p begin="00:02:12.172" end="00:02:15.492" style="s2">the long saphenous and<br />common femoral veins.</p>
<p begin="00:02:15.492" end="00:02:17.455" style="s2">So at this point what I do, is I just</p>
<p begin="00:02:17.455" end="00:02:19.256" style="s2">use my compression technique.</p>
<p begin="00:02:19.256" end="00:02:22.685" style="s2">So I just push with the<br />transducer down until I see</p>
<p begin="00:02:22.685" end="00:02:27.635" style="s2">both walls of the vein coapt<br />or touch and meet each other.</p>
<p begin="00:02:27.635" end="00:02:29.933" style="s2">If I get a complete coapt like this</p>
<p begin="00:02:29.933" end="00:02:32.882" style="s2">I know there's nothing<br />between those two walls,</p>
<p begin="00:02:32.882" end="00:02:36.381" style="s2">so there's no venous<br />thrombosis in the vein.</p>
<p begin="00:02:36.381" end="00:02:38.724" style="s2">So again, just compress down until</p>
<p begin="00:02:38.724" end="00:02:42.032" style="s2">you see those two walls meet completely.</p>
<p begin="00:02:42.032" end="00:02:44.528" style="s2">You'll see that the<br />artery does not compress,</p>
<p begin="00:02:44.528" end="00:02:47.278" style="s2">and is pulsatile beside the vein.</p>
<p begin="00:02:50.968" end="00:02:53.225" style="s2">Now that you've identified your landmarks,</p>
<p begin="00:02:53.225" end="00:02:57.250" style="s2">you wanna do a thorough<br />evaluation of that area.</p>
<p begin="00:02:57.250" end="00:03:00.899" style="s2">So again placing the transducer<br />at the inguinal crease,</p>
<p begin="00:03:00.899" end="00:03:04.441" style="s2">we're going to compress the<br />area of the common femoral vein.</p>
<p begin="00:03:04.441" end="00:03:07.944" style="s2">We wanna move a few<br />centimeters proximal to this,</p>
<p begin="00:03:07.944" end="00:03:10.069" style="s2">so superiorly on the body,</p>
<p begin="00:03:10.069" end="00:03:12.457" style="s2">and we'll start a compression technique.</p>
<p begin="00:03:12.457" end="00:03:15.326" style="s2">Making sure that those<br />walls collapse completely,</p>
<p begin="00:03:15.326" end="00:03:17.397" style="s2">and we just work through this area</p>
<p begin="00:03:17.397" end="00:03:19.814" style="s2">compressing every centimeter.</p>
<p begin="00:03:22.658" end="00:03:26.802" style="s2">We see our common femoral<br />vein and saphen junction here,</p>
<p begin="00:03:26.802" end="00:03:28.905" style="s2">and we can continue compressing</p>
<p begin="00:03:28.905" end="00:03:31.738" style="s2">just a few centimeters below this.</p>
<p begin="00:03:32.790" end="00:03:35.369" style="s2">On the ultrasound we've<br />seen the division to</p>
<p begin="00:03:35.369" end="00:03:38.277" style="s2">superficial femoral artery<br />and profunda artery.</p>
<p begin="00:03:38.277" end="00:03:40.360" style="s2">Just lateral to the vein,</p>
<p begin="00:03:41.348" end="00:03:45.258" style="s2">and then we should see the vein divide to</p>
<p begin="00:03:45.258" end="00:03:48.377" style="s2">femoral vein and profunda vein.</p>
<p begin="00:03:48.377" end="00:03:51.252" style="s2">Again, compressing all the way down,</p>
<p begin="00:03:51.252" end="00:03:53.585" style="s2">until you see this junction.</p>
<p begin="00:03:54.782" end="00:03:59.767" style="s2">From here I'm going to move<br />down to the popliteal region.</p>
<p begin="00:03:59.767" end="00:04:02.031" style="s2">Just move the system<br />down towards the knee,</p>
<p begin="00:04:02.031" end="00:04:05.951" style="s2">and we're going to actually<br />go behind the knee.</p>
<p begin="00:04:05.951" end="00:04:09.951" style="s2">Putting the transducer<br />into the popliteal fossa.</p>
<p begin="00:04:11.592" end="00:04:14.326" style="s2">Once you've identified the<br />popliteal artery and vein,</p>
<p begin="00:04:14.326" end="00:04:15.759" style="s2">mid-popliteal fossa level,</p>
<p begin="00:04:15.759" end="00:04:18.269" style="s2">you wanna evaluate above<br />and below this area</p>
<p begin="00:04:18.269" end="00:04:19.833" style="s2">to make sure you evaluate all those areas</p>
<p begin="00:04:19.833" end="00:04:21.456" style="s2">for deep vein thrombosis.</p>
<p begin="00:04:21.456" end="00:04:24.228" style="s2">So we're going to start mid-level,</p>
<p begin="00:04:24.228" end="00:04:27.790" style="s2">and just work our way<br />superiorly in the leg.</p>
<p begin="00:04:27.790" end="00:04:30.678" style="s2">To the superior aspect<br />of the popliteal fossa.</p>
<p begin="00:04:30.678" end="00:04:32.731" style="s2">Compressing all the way.</p>
<p begin="00:04:32.731" end="00:04:35.767" style="s2">We go up a few centimeters,</p>
<p begin="00:04:35.767" end="00:04:37.929" style="s2">and then we start to move down the leg</p>
<p begin="00:04:37.929" end="00:04:42.802" style="s2">compressing into the inferior<br />aspect of the popliteal fossa.</p>
<p begin="00:04:42.802" end="00:04:45.188" style="s2">Again making sure that those vein walls</p>
<p begin="00:04:45.188" end="00:04:47.513" style="s2">actually touch and meet each other,</p>
<p begin="00:04:47.513" end="00:04:50.506" style="s2">so we know that there's<br />no deep vein thrombosis</p>
<p begin="00:04:50.506" end="00:04:52.738" style="s2">that's fresh which would<br />be h-ai-p-oe-c-u-g.</p>
<p begin="00:04:52.738" end="00:04:54.594" style="s2">Could be difficult to see if we did not</p>
<p begin="00:04:54.594" end="00:04:57.110" style="s2">do this compression technique.</p>
<p begin="00:04:57.110" end="00:04:59.239" style="s2">Those are the two steps<br />for assessing the leg</p>
<p begin="00:04:59.239" end="00:05:00.502" style="s2">for deep vein thrombosis.</p>
<p begin="00:05:00.502" end="00:05:02.501" style="s2">It's just these two evaluation points.</p>
<p begin="00:05:02.501" end="00:05:05.977" style="s2">But just make sure that you<br />evaluate each area thoroughly,</p>
<p begin="00:05:05.977" end="00:05:10.060" style="s2">and you do your compression<br />technique completely.</p>