Skip the ER: Why POCUS Is a Game-Changer for DVT Diagnosis in Urgent Care

Point-of-care ultrasound (POCUS) is transforming the way urgent care and emergency medicine providers manage acute presentations. One of the most critical applications of POCUS is in the diagnosis of deep vein thrombosis (DVT), a potentially life-threatening condition. This blog post, based on a recent case report published in Urgent Caring, the official publication of the College of Urgent Care Medicine (check it out here; go to page 12!), demonstrates the value of POCUS in ruling out DVT, avoiding unnecessary delays, and improving patient outcomes in urgent care settings. [1]

Case Overview

In this case, a 52-year-old man presented with left calf pain following a transcontinental flight. His pain began shortly after the flight, and although he reported no swelling, redness, or warmth, the possibility of a DVT had to be considered. Given his Wells score of 0, the patient was at low risk for DVT. However, due to the delay in obtaining a D-dimer test result, a POCUS was performed in the urgent care clinic. The scan showed full compressibility of the proximal leg veins, ruling out a proximal DVT, and avoiding a referral to an imaging center or emergency department (ED). The patient was reassured, and his D-dimer results return negative in 4 days. No further workup for a DVT was necessary.

Evidence-Based DVT Workup

Managing patients with suspected DVT relies on clinical tools such as the Wells score and D-dimer testing. In this case, the patient’s Wells score was 0, placing him in a low-risk category. According to standard guidelines, if a patient falls within this category and the D-dimer is negative, further diagnostic imaging is unnecessary.

 However, in urgent care settings, D-dimer test results are not always immediately available, as in this case. Here, POCUS proved to be invaluable, allowing immediate evaluation and reassurance. Had the POCUS been inconclusive or positive, follow-up imaging or treatment would have been necessary, but the negative scan allowed the patient to be managed expectantly.

The Role of POCUS in Urgent Care

POCUS for DVT is an established technique in emergency medicine settings. The scan typically assesses proximal deep veins of the lower extremity (the common femoral, popliteal, and femoral veins) through compressibility tests. If the veins can be fully compressed with the ultrasound probe, DVT is unlikely. See Figure 1 below. In this case, the ability to immediately assess the patient using POCUS allowed the urgent care physician to make a confident diagnosis, avoiding unnecessary delays and costs associated with referrals to radiology or emergency departments.

Figure 1: This figure demonstrates the junction of right Common Femoral Vein (CFV) and right Great Saphenous Vein (GSV) known as saphenofemoral junction (SFJ). Note the location of the Common Femoral Artery (CFA) lateral to the veins. On the left panel, no force is being applied on the transducer, and GSF, CFV, and CFA are all visualized. On the right, force is being applied and the venous structures are completely collapsed with the walls of the vessel touching, while the CFA is not. This indicates absence of a clot in the vein.

The decision to perform POCUS in this scenario provided several benefits:

• Improved patient satisfaction: The patient appreciated the immediate assessment and reassurance that his symptoms were not caused by a DVT. Had POCUS not been available, he would likely have been referred for an external ultrasound, potentially increasing his anxiety.

• Cost savings: Avoiding a referral to the ED saved both the patient and the healthcare system significant costs. The average cost for an ED visit in the U.S. is approximately $2,000, whereas a POCUS scan performed in urgent care costs around $116 based on Medicare rates.

• Rapid and informed clinical decision-making: POCUS allowed the physician to confidently rule out a life-threatening condition and prescribe appropriate conservative treatment for the patient’s muscle strain, with no unnecessary delays.

Clinical Pathway for DVT in Urgent Care

When a patient presents with a suspected DVT, an evidence-based approach is crucial for proper management. Figure 2 shows a sample clinical pathway based on the latest evidence and guidelines that could be applied in an urgent care setting.  

Figure 2: Sample Clinical Pathway for a DVT Rule-Out in Urgent Care

Limitations and Considerations

While POCUS is highly effective in ruling out proximal DVT, it has some limitations. The most significant limitation is its reduced sensitivity for detecting isolated distal clots in the calf veins, which may require more advanced imaging techniques.

 Vascular POCUS also comes with a learning curve. A recent metanalysis showed pooled sensitivity and specific of 95% when POCUS was performed by “specialist” emergency physicians (meaning attendings, not trainees) and a 3-point scan was done (includes femoral vein in addition to traditional views). Trainees had a sensitivity of only 77%. [2] This highlights the importance of completing a full training program before using POCUS diagnostically.

 Another important consideration is patient adherence. If there is concern that a patient may not follow through with a scheduled formal ultrasound, performing POCUS at the point of care becomes even more critical in preventing complications such as pulmonary embolism.

Conclusion

This case demonstrates the value of POCUS in an urgent care setting for the evaluation of a patient with suspected DVT. With growing emphasis on patient-centered care, POCUS provides a rapid, cost-effective, and reliable diagnostic tool that enhances clinical decision-making, reduces healthcare costs, and improves patient satisfaction.

The ability to perform bedside ultrasound is increasingly becoming a standard of care in urgent care settings. By integrating POCUS into the diagnostic workflow, like the one presented here, clinicians can more effectively manage acute presentations, such as DVT, and ensure that patients receive timely and accurate care. 

For more detailed information on DVT management and POCUS, you can refer to the full case report published in Urgent Caring or reach out to us at Hello Sono for professional guidance.

Authored by Tatiana Havryliuk, MD

References 

[1]  Havryliuk T. “Case Study: Swollen leg on a Friday Night Case Report.” Page 12. Accessed: October 17, 2024. [Online]. Available: https://urgentcareassociation.org/wp-content/uploads/Urgent-Caring-Q3-2024.FINAL-v8.pdf

[2]  Hercz D, Mechanic OJ, Varella M, Fajardo F, Levine RL. Ultrasound Performed by Emergency Physicians for Deep Vein Thrombosis: A Systematic Review. West J Emerg Med. 2024 Mar;25(2):282-290. doi: 10.5811/westjem.18125. PMID: 38596931; PMCID: PMC11000565.