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ADOM MASTERY FOR HEMATOLOGISTS 

 

PART I. Ultrasound Diagnosis of DVT in Patients with Hypercoagulability 

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Course Objectives​

 

At the end of this course the student should be able to:

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1. Understand the primary and secondary symptoms for deep vein thrombosis.

2. Obtain a medical history, evaluate the patient's symptoms and perform a clinical exam to ensure a peripheral venous ultrasound is indicated.

3. Assess patient symptoms for urgent vs. routine venous ultrasound protocol.

4. Identify the cause of Acute Respiratory Distress Syndrome (ARDMS) in symptomatic patients with suspected Deep Vein Thrombosis (DVT). (Fat Embolism Clinical Scoring Chart)

5. Understand the basic physics of ultrasound to be able to select and maneuver transducers, identify anatomy, physiology and pathology while imaging.

6. Prepare for and perform the patient exam using proper ergonomics to prevent injury.

7. Properly drape and prepare the patient for the ultrasound examination.

8. Be able to perform a peripheral venous ultrasound using a handheld ultrasound system.

9. Recognize useful imaging artifacts when performing a venous ultrasound.​

10. Use gray scale, color and Doppler images to evaluate the peripheral veins with ultrasound.

11. Identify normal venous anatomy in the upper extremity deep and superficial veins with ultrasound.

12. Identify normal venous anatomy lower extremity deep and superficial veins with ultrasound.

13. Differentiate between deep and superficial vein thrombus on ultrasound.

14. Differentiate between acute vs. subacute venous thrombus on ultrasound.

15. Identify and assess chronic residual thrombus with ultrasound.

16. Evaluate venous valve function with ultrasound.

17. Evaluate non-vascular extremity findings with ultrasound.

18. Accurately and efficiently identify and document venous pathology with ultrasound.

19. Evaluate venous duplex waveform patterns to assess for increased central venous pressure / pulmonary embolism vs. heart failure.

20. Evaluate venous waveform patterns to assess severity of thrombus.

21. Evaluate the patient's clinical picture to determine the cause of their thrombus.​

22. Perform urgent protocols in the case of acute deep venous thrombosis, mobile thrombus or Phlegmasia Cerulea Dolens.

23. Use published ultrasound criteria to document and report findings.

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Part I. Course Outline

• Deep Vein Thrombosis

• Vessel Wall​Subendothelial Space

• Collagen

• Connective Tissue

• Tunica Intima

• Endothelial Cells​

• Tunica Media

• Smooth Muscle Cells​ / Collagen

• Tunica Adventitia

• Vaso Vasorum​

• Macrophages, T and B cells

• Endritic & Mast cells

• Microvascular Anatomy​​

• Capillary

• Arteriole

• Venule

• Blood Components

• Red Blood Cells

• White Blood Cells

• Platelets / Thrombocytes

• Blood Plasma

• Ions​

• Proteins

• Lipids​

• HemostasisPrimary​ - Platelet Adhesion​

• Megakaryocyte 

• Glycoprotein 1B-IX-V (GP1B)

• Hemostatic Plug

• Secondary

• Fibrin / Fibrin​ogen

• Thrombin

• Coagulation Cascade​​

•  

• Origin / Causes Virchow's Triad

• Stasis 

• Hypercoagulability 

• Vessel wall injury 

• Cancer

• Proteins 

• Risk FactorsPre-disposing 

• Age 

•  

• Cancer 

• Prolonged bed rest or inactivity 

• Prior episode of DVT 

• Trauma 

• Hormones 

• Paraplegia 

• Surgery 

• Pregnancy 

• Thrombophilias 

• Normal Sonographic Features Lower Extremity Veins​​​Anatomy Deep

• IVC

• Iliac

• Femoral

• Superficial Femoral

• Deep Femoral

• Popliteal

• Posterior Tibial

• Anterior Tibial

• Peroneal

• Gastrocnemius

• Soleal

• Superficial

• Greater Saphenous

• Lesser Saphenous 

• Normal Sonographic Features Upper Extremity Veins​​​Anatomy Deep

• Jugular

• Subclavian

• Axillary

• Brachial

• Radial

• Ulnar

• Superficial

• Cephalic

• Basilic

• Physiology

• Waveforms

• Hydrostatic Pressure

• Abnormal Sonography Features

• Pathology & Pathophysiology

• Waveforms

• Hydrostatic Pressure

• History & Physical 

• Population / Statistics / Likelihood

• Indications & Symptoms

• Lab Values

• Diagnostic Considerations

• Sonographic Signs of Pulmonary Embolism

• Venous Thrombus vs. Arterial Embolus

• Acute Respiratory Distress Syndrome 

• Deep Vein Thrombosis vs. Fat Embolism

• ​​Superficial Thrombus 

• When ST is DVT​

• ​​Frozen Valves

• Reflux

• Non-Vascular Findings

• Baker's Cyst​

• Cellulitis

• Venous Ulcers

• Diagnostic CriteriaThrombus 

• Critical / Acute

• Sub-Acute

• Chronic Residual​

• Waveforms​Phasic​

• Grey Scale 

• Color 

• Doppler 

• Augmentation

• Valsalva Maneuver

• Pulsatile

• Grey Scale 

• Color 

• Doppler 

• Augmentation

• Valsalva Maneuver

• Continuous / Absent 

• Grey Scale 

• Color 

• Doppler 

• Augmentation

• Valsalva Maneuver

• Increased Central Venous Pressure vs. Heart FailureWaveform Analysis 

• Grey Scale 

• Color 

• Doppler 

• Augmentation

• Valsalva Maneuver

• Ultrasound Technique

• Ergonomics

• Ultrasound Physics / Transducers / Knobology

• Patient Preparation 

• Communication

• Positioning

• Draping​​

• Urgent Ultrasound Protocol​

• Acute Deep Vein Thrombosis 

• Mobile Thrombus

• Phlegmasia Cerulea Dolens

• Phlegmasia Alba Dolens

• POCUS Ultrasound Protocol

• Upper Extremity​

• Lower Extremity

• Routine Ultrasound Protocol 

• Upper Extremity​

• Lower Extremity​

• Communicating Findings​​

• Patient​

• Interpreting Physician

• DICOM / PACS / Reports

• Other Diagnostic Testing 

• Magnetic resonance venography (MRV) 

• D-dimer assay 

• CTA 

• Treatment 

• Indications for treatment 

• Anticoagulation 

• Thrombolytic therapy 

• Systemic 

• Catheter-directed 

• Vena caval filters 

• Compression stockings 

• Surgery 

• Ligation of perforating veins 

• Stripping or local excision of varicosities/phlebectomy 

• Sclerotherapy 

• Radiofrequency/laser ablation of incompetent saphenous veins ​