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

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. Expand to view reference list * 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.