EM Quick Hits 8 Lemierre’s Syndrome, Clonidine Toxicity, Routine Coag Panel, Anticoagulation Reversal, Mechanical CPR

Key points on Lemiere's Disease

Lemiere's disease is a rare life-threatening condition characterized by thrombophlebitis of the internal jugular vein with bacteremia, commonly caused by anaerobic bacteria. It typically presents in young adults and adolescents with symptoms such as fever, pharyngeitis, anterior cervical lymphadenopathy, and neck mass. Diagnosis is often clinical, as lab tests are nonspecific. Treatment involves broad-spectrum antibiotics, typically piptazo for toxic patients and a penicillin plus clinomycin or anpicillin cell back-dam for non-toxic patients. It is essential to consider Lemiere's disease in patients with prolonged pharyngitis, worsened symptoms, neck pain, and signs of metastatic disease.

Key insights on clonidine toxicity

Clonidine is a commonly prescribed medication for various indications, including ADHD, opioid withdrawal, and hypertension. In cases of clonidine overdose, measures to stabilize the patient's airway, breathing, and circulation are crucial. Naloxone, typically administered at doses of 5-10 mg, has been found to be effective in reversing the central effects of clonidine toxicity, such as decreased level of consciousness, bradycardia, hypotension, and pinpoint pupils. However, the use of naloxone should be weighed against the potential thrombotic complications. Close monitoring and supportive care, including intubation and vasopressor support if needed, are also important in managing clonidine toxicity.

Dispelling myths about coagulation panels

Coagulation panels, which include tests like PT, APTT, INR, are often overordered in clinical practice, leading to unnecessary costs and time. In patients with low-risk chest pain, perioperative evaluation, and pre-admission screening, routine coagulation testing has little impact on clinical management or outcomes. Instead of ordering indiscriminate coag panels, clinicians should consider individual patient factors and indications for specific tests. Practicing good antibiotic stewardship, using appropriate tests, and considering the clinical scenario can help avoid unnecessary coagulation panel testing.

Updates on anticoagulant reversal

Reversing anticoagulation is an important consideration in patients with life-threatening bleeding. The choice of reversal agent depends on the specific anticoagulant involved. For warfarin, prothrombin complex concentrate (PCC) along with IV vitamin K is the typical treatment. For dabigatran, PCC or the costly andexanet alfa can be considered. In the case of 10A inhibitors (such as apixaban, rivaroxaban, and edoxaban), PCC is the recommended reversal agent. Mechanical CPR has not shown definitive improvement in survival compared to high-quality manual CPR. However, it may be beneficial in settings with limited resources, long transport times, or for patients undergoing PCI or with refractory ventricular fibrillation. The choice to use mechanical CPR should be based on careful consideration of the specific clinical context.

Emergency Medicine Cases

EM Quick Hits 8 Lemierre’s Syndrome, Clonidine Toxicity, Routine Coag Panel, Anticoagulation Reversal, Mechanical CPR

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Quick takeaways

Deep dives

Key points on Lemiere's Disease

Key insights on clonidine toxicity

Dispelling myths about coagulation panels

Updates on anticoagulant reversal

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