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You got a POCUS Question? Put up your hand!

November 9, 2017 2 Comments

Since we went to the format with EDE 2 of putting all of the old PowerPoint presentations online in an interactive format, we have offered to answer the questions of participants as they work through the modules in getting ready for the live part of the course. This is intended to mimic a classroom where you can put up your hand. This is just the online equivalent đŸ™‚

We recently received a question from a participant at an upcoming course and thought it was worthwhile posting the Q&A on the blog.

Question:
I have a question regarding positioning the patient for the popliteal portion of DVT EDE. What do you think of having them lie prone with a pillow under their anterior ankle to gently flex the knee? It seems to me that it would be more comfortable for the examiner and the patient and free up the hand that would otherwise have to support the patella.

Answer:
That’s a good question. When I was first learning to do the DVT scan years ago, I did try that position. I found that it ended up being too cumbersome. A lot of the patients we scan are a bit obese and have some trouble lying flat on their stomachs for any length of time. Another issue is that it simply takes longer for somebody to turn all the way onto the stomach as opposed to just turning on their side (see image below). If I can save 30 seconds in the ED, I will! I scan in the popliteal region with the patient on their side about 95% of the time. I just find it faster to do the scan if they are on their side as opposed to being fully turned on their stomach. For the 5% of patients who cannot turn at all, I scan them in the supine position, with their knee bent only enough to get the probe under that area. You can do the scan with a patient prone. The results are still reliable. But you definitely need to still bend the knee. If the leg is straight, the veins will flatten and be tougher to see. Don’t forget that you still need to place the patient in reverse Trendeleburg position if you are scanning in the prone position. It helps to distend veins.
Hope that helps!

Feel free to chime in with your own opinion!

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Comments (2)

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  1. Thanks for the tip – I do something similar (taught by the ladies at UTS in Melbourne, Australia). Scanning the LEFT popliteal V I flip the patient into the right lateral decubitus and have them place the left leg on top as you have in the photo. Gets good access to the PV area and you can come up to meet the segment of the vessel that you missed on the way down
    Another tip for distal FV is to push the FV up from below with your hand underneath the leg to compress it against the probe from underneath – especially useful for the painful, cellulitic anterior thigh

    Thanks again!

  2. Hey Cian,
    Thanks for chiming in! That is a good tip! From your comment, I am guessing that you scan the entire thigh. At EDE 2, we do not have folks scan the distal FV. Just 2 regions: in the groin and the pop behind the knee (mind you, a good length of each). Of course, the basis for that is the rarity of the isolated mid-thigh DVT. One qualifier that we mention at the course is that if one wants to scan the whole thigh in a certain patient where you are more concerned (e.g. cancer, cast on leg…so higher pre-test prob), then we tell them to go right ahead. It only adds a minute to the scan, once you’ve got some experience under your belt. We point out that the elective scan eats up so much time largely due to the tech burning all those images for the rad and routinely doing all the Doppler maneuvers which almost never add something useful to the final result. Steve P.S. It was good to meet you in MontrĂ©al and present at the same session!

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