Topics in this EM Quick Hits podcast
Anand Swaminathan on Lemierre’s syndrome (0:33)
Emily Austin on clonidine toxicity (06:20)
Brit Long on myths of routine coagulation panel testing (11:48)
Hans Rosenberg and Michael Ho on reversal of anticoagulation (17:22) *
Sheldon Cheskes on mechanical CPR (24:00)
*CJEM collaboration quick hit, reviewing ‘Just the Facts’ series
Podcast production, editing and sound design by Anton Helman
Podcast content & blog post by Anand Swaminathan, Brit Long, Emily Austin & Sucheta Sinha, edited by Anton Helman
Cite this podcast as: Helman, A. Swaminathan, A. Austin, E. Long, B. Rosenberg, H. Ho, M. Cheskes, S. EM Quick Hits 8 – Lemierre’s Disease, Clonidine Toxicity, Routine Coag Panel, Anticoagulation Reversal, Mechanical CPR. September, 2019. https://emergencymedicinecases.com/em-quick-hits-september-2019/. Accessed [date].
Lemierre’s Syndrome Clinical Clues
- Lemierre’s syndrome is a rare, life-threatening diagnosis most commonly seen in children and young adults. It is thrombophlebitis of the internal jugular vein with bacteremia, often fusobacterium.
- Patients will frequently be toxic at the time of diagnosis and can have “metastatic” lesions from septic emboli – pneumonia, meningitis, bacteremia, septic joints etc. as well as cranial nerve abnormalities
- Consider the diagnosis in patients with prolonged pharyngitis (>7 days), a history of pharyngitis that improves and then worsens, septic patients with pharyngitis, those with pharyngitis and a second infection (pharyngitis “+1”), and those with signs of deep space infection such as trismus, pain on rotation of the neck, or palpable neck mass.
- Diagnosis is typically made by CT of the neck with contrast.
- Treatment is with broad spectrum antibiotics such as peperacillin-tazobactam or ampicillin-sulbactam usually in the ICU.
- Treatment of all patients with simple pharyngitis with antibiotics does not prevent the development of Lemierre’s.
- LITFL: Lemierre’s Syndrome
- Eilbert W, Singla N. Lemierre’s syndrome. Int J Emerg Med. 2013;6(1): 40.
- Walkty A, Embil J. Lemierre’s Syndrome. NEJM 2019; 381(12): e16.
Clonidine Overdose Management: Naloxone
- Clonidine acts mainly as an alpha-2 adrenergic receptor agonist in the brainstem leading to decreased sympathetic outflow. It also increases an endogenous opioid in the brain called beta-endorphin.
- A typical picture of clonidine overdose is a patient with somnolence, bradycardia, hypotension and pin-point pupils.
- Differential of this presentation includes toxicity with opioids, your “low and slow” poisoning, barbiturates, ethanol, benzodiazepines and non-toxicological causes such as intracranial hemorrhage.
- A retrospective cohort study published in 2018 described using high-doses of naloxone to reverse the somnolence and often bradycardia in pediatric patients with clonidine toxicity. Patients received very high doses of 5 mg or 10 mg IV naloxone, and many received an infusion after. There were no adverse events from the high doses of naloxone.
- Seger DL, Loden JK. Naloxone reversal of clonidine toxicity: dose, dose, dose. Clin Toxicol (Phila). 2018;56(10):873-879.
Utility of Routine PTT, PT, and INR in the ED
- Coagulation panel commonly includes partial thromboplastin time (PTT) or activated partial thromboplastin time (aPTT), prothrombin time (PT), and international normalized ratio (INR).
- There are several myths associated with coagulation panels:
- Myth #1: Coagulation testing is necessary in the evaluation of all chest pain.
- Myth #2: Coagulation testing is necessary for perioperative or pre-procedure assessment.
- Myth #3: Coagulation testing is necessary in patients being admitted as screening for coagulopathy.
- Literature suggests that coagulation panels obtained on these patients does not change management. For patients with low risk chest pain, specifically with negative troponin and normal electrocardiogram, coagulation assessment is not necessary. Routine perioperative coagulation assessment is not recommended. Coagulation testing should not be used for screening purposes in admitted patients, especially with the infrequency of bleeding disorders in asymptomatic patients.
- Avoid bundling tests; rather, order the individual test that is needed.
- For those on antiplatelets and not anticoagulants, a coagulation panel is not helpful.
- Indications for a coagulation panel include patients with evident bleeding, history of unexplained bleeding, presence of severe disease (liver disease, sepsis, cerebrovascular accident, DIC, preeclampsia/HELLP, cholestasis, poor nutrition), those about to receive thrombolytics, or those taking anticoagulants.
- Schwartz D. Utility of routine coagulation studies in emergency department patients with suspected acute coronary syndromes. Isr Med Assoc J 2005;7:502-506.
- Kochert E, Goldhahn L, Hughes I, et al. Cost-effectiveness of routine coagulation testing in the evaluation of chest pain in the ED. Am J Emerg Med 2012;30:2034-2038.
- Pollack CV. Coagulation assessment with the new generation of oral anticoagulants. Emerg Med J 2016;33:423-30.
- Hubbell FA, Frye EB, Akin BV, Rucker L. Routine admission laboratory testing for general medical patients. Med Care 1988;26(6):619–30.
- Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol 2008;140:496-504.
- Segal JB, Dzik WH, Network TMCT. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion 2005;45:1413-1425.
- Peterson P, Hayes TE, Arkin CF, et al. The preoperative bleeding time test lacks clinical benefit: College of American Pathologists’ and American Society of Clinical Pathologists’ position article. Arch Surg 1998;133(2):134–9.
- Kitchens CS. Preoperative PTs, PTTs, cost-effectiveness, and health care reform. Radical changes that make good sense. Chest 1994;106(3):661–2.
- Sramek A, Eikenboom JC, Briet E, Vandenbroucke JP, Rosendaal FR. Usefulness of patient interview in bleeding disorders. Arch Intern Med 1995;155(13):1409–15.
Additional FOAMed resources
emDocs – When to obtain coagulation tests in the ED
Anticoagulation Reversal: Review of CJEM’s ‘Just the Facts’ series
- Consider reversal of anticoagulation if there is a life-threatening or major bleed.
Reversal by anticoagulant:
- Warfarin: Vitamin K inhibitor
- An INR should guide reversal, unless there is an immediate life-threat requiring immediate reversal. PCC (Octaplex in Canada) combined with IV vitamin K are the agents of choice.
- Make sure to repeat the INR 30 minutes and 6 hours post PCC dose.
- Dabigatran: Factor IIa inhibitor
- If they have a normal aPTT there is likely not a large burden of dabigatran. If you are able to get a normal Thrombin time, this excludes dabigatran.
- For reversal, PCC is the main stay.
- Idarucizumab (Praxbind) is an agent available currently for reversal however it has not been studied compared to a control group. Its use is controversial but not unreasonable.
- Apixaban, Rivaroxaban, Edoxaban: Factor Xa inhibitors
- The only available agent for reversal in Canada is PCC. Studies with PCC do not have control groups.
- In the US Andexanet Alpha may reverse blood peramers, however it is very expensive, has a high risk of thrombosis and has not been shown to improve patient oriented outcomes. Therefore it is not currently recommended by our experts.
- Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e44S-e88S.
- Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019;94(6):697-709.
- Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017;70(24):3042-3067.
What is the evidence behind mechanical CPR?
- The original ASPIRE trial on mechanical CPR was stopped early because patients had worse outcomes with mechanical CPR as a result of prolonged interruptions in CPR when placing the device. However, the trial was conducted before the importance of high quality uninterrupted CPR was recognized.
- Recent studies show that if the device is place on the patient quickly high quality CPR is achievable, but do not show any survival benefit when compared to high quality manual CPR.
“The Cheskes 7”: When to consider Mechanical CPR
- Few resources and people (eg. rural settings)
- Long transport times
- Manual CPR quality is not assessed (this often means CPR quality is poor)
- Emergency department CPR (rarely studied and often shown to be of poor quality)
- The PCI lab
- Refractory Ventricular Fibrillation going to ECMO
- Heads up CPR (having the patient’s head elevated in CPR may improve perfusion to the heart and brain but is not possible with manual CPR)
- Paradis NA, Young G, Lemeshow S, Brewer JE, Halperin HR. Inhomogeneity and temporal effects in AutoPulse Assisted Prehospital International Resuscitation–an exception from consent trial terminated early. Am J Emerg Med. 2010;28(4):391-8.
- Bonnes JL, Brouwer MA, Navarese EP, et al. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med. 2016;67(3):349-360.e3.
- Yannopoulos D, Bartos JA, Martin C, et al. Minnesota Resuscitation Consortium’s Advanced Perfusion and Reperfusion Cardiac Life Support Strategy for Out-of-Hospital Refractory Ventricular Fibrillation. J Am Heart Assoc. 2016;5(6).
- Ryu HH, Moore JC, Yannopoulos D, et al. The Effect of Head Up Cardiopulmonary Resuscitation on Cerebral and Systemic Hemodynamics. Resuscitation. 2016;102:29-34.
None of the authors have any conflicts of interest to declare