Frazee B W, Snoey E R, Levitt A
Department of Emergency Medicine, Alameda County Medical Center, Highland Campus, 1411 East 31st Street, Oakland, CA 94605, USA.
J Emerg Med. 2001 Feb;20(2):107-12. doi: 10.1016/s0736-4679(00)00302-4.
Emergency Department (ED) patients with suspected deep vein thrombosis (DVT) require an objective vascular study such as ultrasound (US) to confirm the diagnosis prior to treatment or disposition. A simple compression US test of the common femoral vein and popliteal vein reliably detects proximal DVT in symptomatic patients. Application of compression US in the ED by Emergency Physicians (EPs) has been tested in a single previous study. We evaluated the ability of ED compression US, performed by EPs, to diagnose proximal DVT as compared to duplex US performed in a vascular laboratory. A prospective, observational study was conducted on a convenience sample of patients presenting to an ED with lower extremity symptoms and signs suggestive of DVT. Patients with a history of DVT in the symptomatic extremity were excluded. Final diagnosis of DVT was made by color-flow duplex US performed in a vascular laboratory. ED compression US was performed by one of six EP sonographers. In compression US, DVT was diagnosed by the inability to compress the common femoral vein or popliteal vein. The examination was considered indeterminate if the veins could not be clearly identified or compressibility was equivocal. For statistical analysis, an indeterminate examination was considered positive. In those cases where ED compression US was discordant with duplex US, and not indeterminate, we retrospectively reviewed the US findings. There were 76 patients who completed the study, and 18 patients (24%) were diagnosed with DVT by duplex US, among whom ED compression US was positive in 14, negative in 2, and indeterminate in 2. Among 58 patients diagnosed without DVT by duplex US, there were 4 false-positive ED compression US examinations and 10 indeterminate examinations. In all, ED compression US was indeterminate in 12 patients (15.8%). Compared to duplex US, ED compression US had a sensitivity of 88.9% (95% C.I. 65.3-98.6%) and specificity of 75.9% (62.8-86.1). Negative predictive value was 95.7% (85.2-99.5). Among ED patients with the clinical diagnosis of possible DVT, negative ED compression US greatly reduces the likelihood of DVT, such that discharge and outpatient follow-up can be considered. Because of limited specificity, positive results require confirmation, but may justify immediate treatment pending follow-up testing. Indeterminate results can be expected in a significant number of patients and mandate further testing prior to disposition.
疑似深静脉血栓形成（DVT）的急诊科（ED）患者在治疗或处置前需要进行客观的血管检查，如超声（US）检查以确诊。对股总静脉和腘静脉进行简单的压迫超声检查能够可靠地检测出有症状患者的近端DVT。此前有一项研究对急诊科医生（EP）在急诊中应用压迫超声进行了测试。我们评估了由急诊科医生进行的急诊压迫超声与血管实验室进行的双功超声相比，诊断近端DVT的能力。我们对一组方便样本进行了一项前瞻性观察性研究，这些患者因下肢症状和体征提示DVT而就诊于急诊科。有症状肢体有DVT病史的患者被排除。DVT的最终诊断通过血管实验室进行的彩色血流双功超声检查确定。急诊压迫超声由六名急诊科超声检查医生之一进行。在压迫超声检查中，若股总静脉或腘静脉无法被压迫则诊断为DVT。如果静脉无法清晰识别或压迫性不明确，则该检查被视为不确定。为进行统计分析，不确定的检查被视为阳性。在急诊压迫超声与双功超声结果不一致且不是不确定的情况下，我们回顾性地复查了超声检查结果。有76名患者完成了研究，其中18名患者（24%）通过双功超声诊断为DVT，其中急诊压迫超声检查结果为阳性的有14例，阴性的有2例，不确定的有2例。在58名通过双功超声诊断无DVT的患者中，急诊压迫超声检查有4例假阳性和10例不确定结果。总体而言，急诊压迫超声检查有12例（15.8%）结果不确定。与双功超声相比，急诊压迫超声的敏感性为88.9%（95%置信区间65.3 - 98.6%），特异性为75.9%（62.8 - 86.1%）。阴性预测值为95.7%（85.2 - 99.5%）。在临床诊断可能为DVT的急诊患者中，急诊压迫超声检查结果为阴性可大大降低DVT的可能性，因此可以考虑出院及门诊随访。由于特异性有限，阳性结果需要进一步确认，但在后续检查之前可证明立即治疗是合理的。预计会有相当数量的患者检查结果不确定，在处置前需要进一步检查。
