Tag Archives: Sequeira

Lemierre’s Syndrome

15 Oct

What is it?  Lemierre’s Syndrome also known as postanginal septicemia refers to thrombophlebitis of the internal jugular vein.  See figure 1 below.


Figure 1:  Red arrow indicating infected thrombus of internal jugular vein.


Signs and Symptoms:  Lemierre’s Syndrome usually develops as a complication of a bacterial pharyngitis in young, healthy adults. Patients usually start with a sore throat, fever, and general body weakness. These are followed by swollen cervical lymph nodes, a tender or painful neck, with continued fevers. Sepsis and even septic shock can ensue. Karkos et. al did systematic review in 2009 looking at 84 studies/114 patients who had Lemierre’s syndrome . Table 1 shows the sources of infections.


Pathophysiology: Lemierre’s syndrome occurs most often when a bacterial throat infection, usually Fusobacterium necrophorum) progresses to the formation of a peritonsillar abscess. When the abscess wall ruptures internally, the drainage carrying bacteria seeps through the soft tissue and infects the nearby structures. Spread of infection to the nearby jugular vein leads to  inflammation surrounding the vein and compression of the vein may lead to clot formation.


Why is it so dangerous?  The infected thrombus of the internal jugular vein is a perfect gateway for the spread of bacteria through the bloodstream. Besides causing sepsis and septic shock, pieces of the infected clot break off leading to septic emboli of the pulmonary vasculature, where abscesses, nodules, cavitary lesions and pleural effusions develop.  Emboli can also affect the joints, muscles and soft tissues, liver, spleen, kidneys and brain.


Treatment:  Fusobacterium necrophorum is generally highly susceptible to beta-lactams, metronidazole, clindamycin and third generation cephalosporins. Additionally, a co-infection by another bacterium may co-exist. For these reasons is often advised not to use monotherapy in treating Lemierre’s syndrome.  The role of anticoagulation in treating Lemierre’s syndrome remains controversial.  Karkos et al. showed overall mortality to be 5%.


Submitted by Joran Sequeira, M.D.



  • Karkos et al. Lemierre’s Syndrome: a systematic review. August 2009. Laryngoscope, 119 (8): 1552-1559.
  • Syed et al. Lemierre syndrome: two cases and a review. September 2007. The Laryngoscope(The American Laryngological, Rhinological & Otological Society; Lippincott Williams & Wilkins). 117 (9): 1605–1610



Anterior Epistaxis: When compression isn’t enough

25 Aug

Usually patients come back from triage with some form of compression, be it fingers, tongue-blades, clothespin… Compression should be held for at least 20-30 minutes


If still actively bleeding, first thing is to clean out the nose. Have them blow out all clots (ONCE.  Not every 5 minutes)

Take a look to make sure an anterior bleed, and where exactly that bleed is.

If compression not working, here are some options:


Afrin:  Afrin or phenylephrine is a vasoconstrictor which usually does the trick


LET or 4% Lidocaine:  the UVA ER is stocked with Epistaxis kits which have nasal cannula, cotton balls, small plastic cup. 

Put 5-10cc 4% Lidocaine into cup, Dab cotton or gauze in the lidocaine, squeeze excess and apply to bleeding site.

Alternatively, using LET (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%)


Silver nitrate:  If site dry, can apply Chemical cautery with silver nitrate. Roll on site.epi1


Surgicel:  Surgicel is fast-acting absorbable hemostat material. Cut to fit and place over site. Absorbs in
7-10 days.


Nasal packing or Rapid Rhino: Rapid Rhino is an inflatable balloon coated with a compound that eip2acts as a platelet aggregator and also forms a lubricant upon contact with water. Different sizes available.


Extra Pearls:

  • Once bleeding stopped, make sure the patient walks, bends down, squats to make sure no re-bleeding.
  • ENT follow-up if persistent problem.
  • Admit if cannot get it under control.



Submitted by Joran Sequeira, MD.


References: Gilman, Charles. “Focus on: Treatment of Epistaxis”. June 2009. ACEP News.

Proximal 5th Metatarsal Fractures

24 Jul


meta1 meta2 meta3 meta4



Submitted by Joran Sequeira.



• Ramponi et al. Proximal fifth metatarsal fractures. Adv Emerg Nurs J. 2013. 35 (4): 287-92

• Strayer et al. Fractures of the Fifth Metatarsal. 1999. Am Fam Physician. 59 (9): 2516-2522

• Radiopedia.org

Left Anterior vs. Posterior Fasicular Blocks

16 Jun

Left Anterior Fasicular Block (more common of the two)

  • Left axis deviation (usually between -45 and -90 degrees)
  • Small Q waves with tall R waves in leads I and aVL
  • Small R waves with deep S waves in leads II, III, aVF



Left Posterior Fasicular Block (almost always associated with RBBB)

  • Right axis deviation (> +90 degrees)
  • Small R waves with deep S waves in leads I and aVL
  • Small Q waves with tall R waves in leads II, III and aVF



Clinical Significance

  • By itself with no symptoms, these blocks are not significant. May indicate underlying CAD which led to impairment or that the patient is at risk for progressing to LBBB.
  • LAFB can be seen in about 4% of acute MI cases. It is the most common type of intraventricular conduction defect seen in acute anterior MI, the LAD usually the involved vessel.
  • LPFB plus RBBB in acute MI associated with high mortality rate.  However, CAD is less common in RBBB with LPFB than in RBBB with LAFB or isolated LAFB.


Submitted by Joran Sequeira.


References: Biagani et al. Prognostic Significance of Left Anterior Hemiblock in Patients With Suspected Coronary Artery Disease. Journal of the American College of Cardiology. Volume 46, Issue 5, 6 September 2005, Pages 858–863; Elizari et al. Hemiblocks revisited. Circulation. 2007; 115: 1154-1163

Xray Findings in Subtle Calcaneus Fractures

12 Dec

Interesting Fact

A calcaneus fracture is also known as a Lover’s fracture, Don Juan fracture or Casanova Fracture (consequence of jumping from a bedroom window onto a hard surface).

Calcaneus fractures are most often caused by falling from a significant height onto one’s feet.  ED physicians should always consider the possibility that a fractured calcaneus might be bilateral, and/or associated with thoracic or lumbar fractures. 

X-ray findings to aid in the diagnosis

Subtle calcaneus fractures are sometimes hard to visualize on an xray which is why radiologists, orthopedists and ED physicians sometimes use Boehler’s angle and critical angle of Gissane.


Boehler’s angle

On a lateral view, this angle is formed by the intersection of two lines. 

  • The first line from the upper edge of the calcaneal body posteriorly to the upper edge of the posterior articular facet of the calcaneus at the subtalar joint. 
  • The second line is drawn from this point to the upper edge of the anterior process of the calcaneus.  If the angle is < 30 degrees, most likely there is a calcaneus fracture.


The first image demonstrates a Boehler’s Angle of 21 degrees suggesting that there is a fracture of the calcaneum. Compare this with the normal anatomy on the right.

Critical angle of Gissane

Measured on lateral xray, this is the angle formed by the downward and upward slopes of the calcaneal superior surface. This angle is usually between 95° and 105°. An angle of Gissane of greater than 130° suggests fracture of the posterior subtalar joint surface.


Figure: Normal critical angle of Gissane

In 2006, Knight et al., published a randomized case-control trial in the American Journal of Emergency Medicine evaluating the use and aid of Boehler’s angle (BA) and critical angle of Gissane (CAG).  They found that the BA was somewhat helpful in aiding physicians to make the diagnosis of fracture, whereas the CAG was not helpful.  There have not been many repeat studies done on this topic since.

Submitted by J. Sequeira.

References: Knight JR et al. Boehler’s angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED. 2006. Am J Emerg Med, Jul; 24 (4): 423-427; http://www.wikiradiography.com/page/Calcaneal+Fractures