Journal Club Article Summary: Proximal venous ultrasound with risk stratification safely excludes deep venous thrombosis in emergency department routine care
- Mar 30
- 2 min read
“Never Skip Leg Day: Should We Ultrasound Every
Swollen Leg in the ED?”
By Jonny Russell
In EMUGs we rarely skip an opportunity to use ultrasound, but should we be scanning every swollen leg — or is it safe for some patients to “skip leg day”? This paper examined whether emergency physician–performed proximal compression ultrasound (PUL), combined with clinical risk stratification, could safely diagnose or exclude lower-limb DVT directly in the emergency department. In this prospective
observational study of 560 patients, all participants with clinical concern for a
possible DVT underwent ED POCUS.
Results
DVT prevalence was 18.4%, and 82.5% of patients were managed entirely within the ED without referral to radiology. Among 381 patients discharged with DVT ruled out, two were subsequently diagnosed with DVT/PE within 30 days, giving a reported negative predictive value of 99.5% and sensitivity of 97.8%.
Discussion
Discussion at EMUGs journal club focused less on the headline diagnostic performance and more on how this translates to real-world ED practice. Participants noted that lower-limb venous ultrasound can be a time consuming and technically challenging examination, particularly in patients with difficult body habitus or surprisingly common anatomical variations in their venous anatomy (30-60% of people have at least one significant variant in their deep venous anatomy, most commonly femoral vein duplication). Several in the group felt comfortable using POCUS as a rule-in test, but were less confident relying on it as a definitive rule-out, particularly given the difficulty identifying below-knee DVT and the possibility of more proximal iliac vein thrombosis being missed using a limited scan protocol. Another point of discussion was that the study protocol performed POCUS on every patient, rather than using a Wells score plus D-dimer strategy to rule out DVT in low-risk patients without imaging, which is common practice in most EDs. In that sense, the study primarily demonstrates the feasibility of relocating ultrasound from the radiology department into the ED, rather than reducing the overall use of imaging.
Several clinicians described using POCUS pragmatically as a risk-stratification tool while awaiting formal radiology ultrasound, especially when imaging may be delayed for several days. Identification of thrombus on POCUS supports early anticoagulation, while a negative study may justify withholding empiric treatment pending definitive imaging, especially in patients with an increased bleeding risk.
Training and governance considerations were also raised. The study required clinicians to complete an 8-hour training course, pass MCQ and DOPS assessments, and log a minimum of 20 scans to achieve credentialing, which may represent a significant training and governance hurdle for departments attempting to implement this pathway at scale. Additionally, in many departments, POCUS images are not reliably archived or linked to the electronic medical record, which is problematic when initiating potentially harmful treatments such as anticoagulation without a permanent record of objective imaging findings.
Finally, it was highlighted that this was not a true diagnostic accuracy study, as scans were not systematically compared with a gold-standard reference test. Rather, it represents a pragmatic safety study evaluating a clinical protocol with 30-day follow-up. While interesting from a workflow perspective, the group felt the evidence was insufficient to change current practice.
Bottom line
ED-performed POCUS may help expedite diagnosis or guide interim management while awaiting formal imaging, but based on this study most participants were not comfortable using it as a definitive rule-out test for DVT in place of established Wells score, D-dimer and diagnostic radiology pathways.
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