Homan Sign

[medichopeful]

So here I am, on my winter break from nursing school, studying like a nerd <_<

I was exploring online, and I saw in a forum (allnurses.com or similar) that the use of the Homan sign for diagnosis (I use that word loosely, as it only occurs in something like 30-50% of cases) of DVT can cause the thrombus to dislodge and cause a PE. I did an online search for this, but haven't really found too much besides 2 articles that I haven't finished reading.

Regardless of the reliability of this test, does anybody have any references saying that Homan's sign can do this?

Thanks all!
Eric

 

[mycrofft]

As lawyers say, anything is possible.

 

[Akulahawk]

So here I am, on my winter break from nursing school, studying like a nerd <_<

I was exploring online, and I saw in a forum (allnurses.com or similar) that the use of the Homan sign for diagnosis (I use that word loosely, as it only occurs in something like 30-50% of cases) of DVT can cause the thrombus to dislodge and cause a PE. I did an online search for this, but haven't really found too much besides 2 articles that I haven't finished reading.

Regardless of the reliability of this test, does anybody have any references saying that Homan's sign can do this?

Thanks all!
Eric

Done correctly, I wouldn't expect a positive Homan's to dislodge a thrombus that wasn't going to dislodge anyway. Movement prevents stasis quite well... so you want to get someone up and moving early, except that movement can also dislodge a thrombus and cause that PE you were trying to avoid. Do I have any specific references from literature? Not right now... I'd have to do more digging than I have a desire to do at the moment.

 

[Commonsavage]

My Nursing rant

Unfortunately, despite all of the emphasis on evidence-based training many, if not most, nursing programs continue to instill more emphasis on fear and a CYA philosophy and keeps many nurses frozen in place...unable to engage in independent critical thinking. As such, there are tons of misinformation and the perpetuation of medical myths passed along.
As far as the Homan's test, in my experience, even with bedside ultrasound and doppler available, I see docs doing it all the time without any immediate ill-effect. Out here, in the boonies without resources, I use it as a pertinent part of my exam. I suspect that the incidence of PE due to LE vascular manipulation is extremely rare. But, it makes for a good horror story to tell impressionable nursing students. I haven't taken the time to fully research incidence of negative outcomes, let us know if you come up with anything...as will I.
BTW, I'm a distance nursing student. Keeps me from throttling nursing instructors.:wacko:

 

[Commonsavage]

Unfortunately, despite all of the emphasis on evidence-based training many, if not most, nursing programs continue to instill more emphasis on fear and a CYA philosophy and keeps many nurses frozen in place...unable to engage in independent critical thinking. As such, there are tons of misinformation and the perpetuation of medical myths passed along.
As far as the Homan's test, in my experience, even with bedside ultrasound and doppler available, I see docs doing it all the time without any immediate ill-effect. Out here, in the boonies without resources, I use it as a pertinent part of my exam. I suspect that the incidence of PE due to LE vascular manipulation is extremely rare. But, it makes for a good horror story to tell impressionable nursing students. I haven't taken the time to fully research incidence of negative outcomes, let us know if you come up with anything...as will I.
BTW, I'm a distance nursing student. Keeps me from throttling nursing instructors.:wacko:

OK, after a quick survey, the only place that I can find a negative reference about using Homan's Sign is on the allnurses website. Here's a coupla other references that may help:

http://cmbi.bjmu.edu.cn/uptodate/va...ach to the patient with venous thrombosis.htm

http://www.cdc.gov/genomics/gtesting/file/print/FBR/VTEDisSet.pdf

So, I'll stand by my earlier statement (rant), and add that when properly performed, the Homan's test should not present any significant risk of dislodging a DVT, and is only one part of a proper exam.

 

[systemet]

Regardless of the reliability of this test, does anybody have any references saying that Homan's sign can do this?

I took a quick look, and couldn't find anything.

Most of the references did find suggest, as you mentioned, that Homan's sign is almost useless for identifying DVT. The numbers vary with the study cited, but it looks like < 1/3rd of patients with DVT have a positive Homan's, and >50% of those with a positive Homan's sign, amongst patient being evaluated for DVT, don't actually have one.

I guess it forms part of a clinical gestalt, but there shouldn't be much significance attached to its presence or absence as an isolated entity.

 

[rook901]

When I went to LPN school in 2005, we were taught to check for Homan's sign. Went back for my RN, and we were taught that it was no longer useful in screening for a DVT, so it's no longer part of your assessment.

I have heard that it can dislodge a DVT, but I could never find any actual literature mentioning this. Regardless, it's best to just not do it and not document it. It's not of any clinical value, and if the patient ever throws a clot, the lawyers will crucify you if they find out that you checked for it.

As others have said, it's CYA to just not do it.

 

[bigbaldguy]

Is Homans sign something you check for on every patient or is there a specific complaint that would make you check for this? DVT is something that can and has occurred during long flights and I was under the impression it generally occurred without any warning.

 

[STXmedic]

Is Homans sign something you check for on every patient or is there a specific complaint that would make you check for this? DVT is something that can and has occurred during long flights and I was under the impression it generally occurred without any warning.

No, just on suspicion of a DVT. Unilateral LE pain, pedal edema, or inflammation would raise some flags. Definitely not every patient.

 

[KellyBracket]

One of the attendings at our ED had worked as an ultrasound tech before med school. He told me about finding a big DVT on an US exam (which involves pushing hard RIGHT ON THE CLOT). Right after he found the clot, the patient started complaining of SOB. Then he couldn't find the clot in the leg anymore...

Homan's sign is mostly a historical question now. It's terrible as a specific exam finding, lots of false positives, false negatives. Don't worry about palpating legs, it's safe. If that's what dislodges the clot, it was just about ready to fly anyway. I can't imagine anyone would ever blame EMS for causing a PE. That ship had already set sail!