29-year-old F presents to ED with acute onset knee pain. Reports hearing an audible “pop” after twisting her leg while running down the stairs at home. She explains that her right knee is stuck, and she can neither flex nor extend it. An image is shown below (courtesy of Andrew Murphy, Radiopaedia.org)
A twenty-year-old right-handed male presented to the emergency department with a past medical history of right coracoid impingement, and three months of increasing right shoulder pain that became suddenly worse. He had a right shoulder arthroscopy nine months ago and played a full season as his baseball team’s pitcher over the past four months. He endorsed no exacerbating symptoms other than movement and has only taken naproxen over the counter for this pain. He denied any family history of clotting disorders.
A fifty-six-year-old male with a past medical history of legal blindness and remote right quadricep tendon rupture presents to the emergency department via emergency medical services (EMS) after a mechanical fall, complaining of left knee pain. According to the patient, he is in his regular state of health and was walking with his cane when he had a mechanical fall on the sidewalk after tripping on an unknown object and falling onto his left knee.
The patient did not hit his head, did not lose consciousness, and has no head, neck, or back pain. The patient states that he fell directly onto his knee and felt a popping upon hitting the ground, and remembers all events surrounding the incident. The patient was not ambulatory prior to coming to the emergency department.
Acute management of cerebrovascular accidents can be challenging enough, but questions about anticoagulant reversal in the setting of hemorrhagic stroke add another layer of complexity. The ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements, reviewed this topic with Dr. Joshua Goldstein (Massachusetts General Hospital, Harvard Medical School). Dr. Goldstein addressed common anticoagulants and their reversal agents, summarizing available literature to inform clinical practice. We present highlights from this discussion with Dr. Jason Woods.
Since it is impossible to go back in time to prevent intracranial hemorrhage (ICH), the focus of management for hemorrhagic stroke should be to prevent further bleeding and allow brain tissue an opportunity to recover. The goal of anticoagulant reversal in patients with ICH is to decrease ongoing bleeding.
Warfarin is a vitamin K antagonist. Since vitamin K is required for the processing of coagulation factors II, VII, IX, and X, patients on warfarin have decreased amounts of these factors in circulation. To increase the availability of these factors, countering the effect of warfarin therapy can be two-fold:
Vitamin K supplementation will not provide immediate effect, and it may take up to 24 hours for the production of new coagulation factors. While it should be given early, patients also require factor replacement acutely.
Fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) can be given to supplement coagulation factors.
Studies have shown PCC to be associated with faster INR reversal, less ICH expansion, and a non-statistical trend toward decreased mortality [1]. PCC does carry a theoretical risk of thromboembolism given the rapid correction, but no evidence exists to suggest that this is the case.
There are 2 categories of DOACs:
Approach to reversal: remove the inhibitor to allow normal function of already existent Factor II or Xa
It should be noted that there are no reliable tests for measuring DOAC activity.
The most common agents are aspirin and Plavix (clopidogrel). The issue with patients on these antiplatelet agents is not a lack of platelets, but the presence of medication that suppresses normal platelet function. Theoretically, if one could provide extra platelets, the inhibiting agent could be saturated and the remaining platelets provide some functional activity.
The PATCH trial demonstrated, however, that platelet transfusion led to significantly worse outcomes [2]. While there is no readily available reversal agent for DAPT, platelet transfusion should be avoided. In fact, observational data suggest that patients on single antiplatelet therapy don’t fare worse and may not need reversal like those with DAPT [3].
Warfarin reversal
Dabigatran reversal
Factor Xa inhibitor reversal
Antiplatelet reversal
Listen to the other ACEP E-QUAL podcasts on our Soundcloud account.
A 17-year-old male baseball catcher presents with right knee pain after an opponent slid into home plate, striking the anteromedial aspect of the patient’s knee while it was in extension trying to block the plate. An x-ray of the tibia and fibula was obtained (courtesy of Dr. Haytham Bedier, Radiopaedia.org).
This is a proximal avulsion fracture of the styloid process of the fibula, indicating injury to the posterolateral corner (PLC) of the knee [1].
This injury usually occurs from varus stress in a hyperextended knee- think a blow to the anteromedial tibia with the knee in extension [2].
The arcuate sign is a horizontal linear lucency through the head of the fibula that represents a fracture of the styloid process [3].
A proximal fibular avulsion fracture is commonly associated with injury to the posterior cruciate ligament, anterior cruciate ligament, popliteus, or meniscus. It is frequently seen with bone contusions and sometimes a tibial plateau fracture [2].
This injury indicates potential significant instability of the knee and requires outpatient follow-up with MRI. Operative management will be dictated on an individual basis, after evaluating MRI results. In the emergency department, place the patient in a knee immobilizer and recommend non-weight-bearing status until further imaging. Follow-up with orthopedics or sports medicine within 1 week.
If diagnosis of this injury is delayed, posterolateral instability may develop. If not recognized and managed appropriately, this may hinder the success of a cruciate ligament reconstruction [1].
Want more information about the knee exam? Check out the SplintER archives.
A 29-year-old female presented to the emergency department for a rash on her right calf. 5 days prior, at her home in Alabama, the patient developed pain and swelling of her right calf following a spider bite while putting on her pants. The patient felt a “burning pain” and found a spider which she then killed. She went to a hospital and received cephalexin, trimethoprim/sulfamethoxazole, and oxycodone. Despite taking these medications she continued having aching pain rated 10/10 in her right calf along with generalized pruritus. The patient stated that the bite evolved from an initial generalized redness into a blue/black lesion with blistering and extensive redness along her leg and torso. She denied fever, chills, lightheadedness, abdominal pain, nausea, vomiting, and hematuria.
A 12-year-old male pitcher for a traveling club baseball team complains of acute worsening of right elbow pain that has been bothering him for 3 months. The radiograph is shown below (Frontal elbow view. Case courtesy of Dr. Levente István Lánczi, Radiopaedia.org, rID: 46853). What is your diagnosis? What causes this injury? What patient demographic is most susceptible to this injury? How can this injury be prevented? What is the management of this injury in the Emergency Department?
