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.