Incidence of Spinal Hematoma from Lumbar Punctures in Patients with a Coagulopathy or Thrombocytopenia

Lumbar Puncture CME
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – coagulopathy, epidural hematoma, featured, HPC updates, lumbar puncture, thrombocytopenia
A recent cohort study using the Danish nationwide medical registry demonstrates that the incidence of a spinal or epidural hematoma from lumbar punctures in patients with pre-existing thrombocytopenia (Platelets<150 K) or coagulopathy (INR>1.4 or aPTT>39 seconds) is not significantly higher…
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Risk of Epidural Hematoma from Lumbar Puncture in Patients with a Coagulopathy

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – coagulopathy, epidural hematoma, featured, HPC updates, lumbar puncture, thrombocytopenia
Class 1 evidence to inform decisions about the safety of lumbar punctures in patients with a coagulopathy are lacking. The only guidance we have regarding the safety of lumbar punctures is based on clinical guidance from organizations such as the…
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Atraumatic Spinal Needles Significantly Decrease the Risk of Post-Dural Puncture Headaches or Spinal Headaches

Lumbar Puncture Training
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, Gastrointestinal diseases, Lumbar Puncture, Medical General, Oncology, Traumatology
More Tags – ATN, Atraumatic spinal needles, featured procedure, HPC updates, lumbar puncture, PDPH, post-dural puncture headache, TN, Traumatic needles
According to recent studies, atraumatic needles (ATN) reduce the rate of post-dural puncture headache (PDPH) when compared to traumatic needles (TN – or bevel-tip needles such as Quincke needles) (27% vs 60%).  Also, the mean duration of PDPH from ATN…
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In-person Procedural Education in the Era of COVID19

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Chest Tube, Emergency Procedures, Featured, Glidescope Intubation, Lumbar Puncture, Paracentesis, Thoracentesis
More Tags – chest tube placement, emergency procedures course, featured, hospital procedures course, HPC updates, intubation, lumbar puncture, medical procedures course, paracentesis, POCUS, thoracentesis, Vascular access
Medical procedural education in the era of COVID19 is still best conducted via HANDS-ON simulation-based procedural training. Procedural skills can NOT be attained via remote education, but in-person training must be conducted safely. There are many topics and skills that can be successfully be taught online,…
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Which cirrhotic patients are at high risk for bleeding during hospital procedures?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, Central line, Featured, Gastrointestinal diseases, Hospital Procedures, Lumbar Puncture, medical procedures, Paracentesis, Ultrasound-Guided Peripheral IV
More Tags – Arterial line placement, central line placement, chest tubes, cirrhosis, featured, HPC updates, lumbar puncture, paracentesis, thoracentesis, tube thoracostomy
This blog will offer some expert recommendations to help guide the safety of hospital procedures at different platelet and coagulation profiles.  Unfortunately, there are no strong evidence-based guidelines for hospital procedures dedicated to the study of patients with decompensated cirrhosis.…
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Which cirrhotic patients are at high risk for bleeding during hospital procedures?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Featured Procedure, Hospital Procedures, Lumbar Puncture, medical procedures, Paracentesis, Thoracentesis
More Tags – Bleed risk, central line, HPC updates, paracentesis, Procedures in Cirrhotic Patients, thoracentesis
How do we assess a cirrhotic patients bleed risk prior to a planned bedside procedure?  Can our standard platelet count and coagulation studies, prothrombin time (PT/INR) and partial thromboplastin time (aPTT), accurately predict bleed risk in cirrhotic patients?  The quick…
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Bedside Ultrasound Increases the Success Rate for Difficult Lumbar Punctures

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured Procedure, Lumbar Puncture, medical procedures
More Tags – featured procedure, HPC updates, lumbar puncture, Ultrasound-Guided Lumbar Punctures, ultrasound-guided procedures
The traditional landmark-guided needle lumbar puncture technique was first described by Heinrich Quincke in 1891[1]This technique utilizes the iliac crest and the posterior lumbar spinous processes to determine the optimal sites for spinal needle introduction in either the L3-4 or…
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Guidelines for Antiplatelet and Anticoagulation Discontinuation before a Lumbar Puncture

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – anticoagulation, antiplatelets, epidural hematoma, featured, HPC updates, lumbar puncture
This blog summarizes the guidelines by the European Society of Anesthesiology (ESA), the American Society of Regional Anesthesia (ASRA) and the Association of British Neurologists regarding the timing of antiplatelet and anticoagulation discontinuation before a lumbar puncture.  The following table…
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Performing Procedures on Patients Who Take Dabigatran, Rivaroxaban, and Apixaban

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured Procedure, Hematology, Lumbar Puncture, medical procedures
More Tags – anticoagulation, bedside procedures, HPC updates, invasive procedures, Oral anticoagulants
Over the past several years, there has been a dramatic increase in the use of the new oral anticoagulants (Dabigatran, Rivaroxaban, and Apixaban).  The popularity of these medications stems not only from aggressive pharmaceutical monitoring to physicians and to the…
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Safety of Lumbar Puncture in Adults and Children with Thrombocytopenia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – HPC updates, lumbar puncture, procedure, thrombocytopenia
Traditionally, it has been promulgated by anesthesiologists that you need a platelet count of 100,000 to safely perform neuraxial regional anesthesia (spinal and epidural anesthesia).  This practice pattern has continued even though Children’s Hospitals routinely perform intrathecal injections for prophylactic chemotherapy with…
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Risks for Post-Dural Puncture Headaches after Lumbar Puncture

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, Lumbar Puncture, Medical General, medical procedures, Paracentesis, Traumatology
More Tags – Headache, HPC updates, lumbar puncture, post-dural puncture headache, spinal headache
Diagnostic lumbar punctures aid in the diagnosis of infections and diseases of the central nervous system. Life-threatening events from lumbar punctures are rare, but post–lumbar (dural) puncture headaches (PDPH) occur in 1% to 36% of patients, depending on the needle…
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Ultrasound-Guided Lumbar Puncture More Successful than Traditional LP in Infants

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Lumbar Puncture, Medical General, medical procedures
More Tags – HPC updates, Infants, lumbar puncture, ultrasound, Ultrasound-guided lumbar puncture
Lumbar puncture (LP), commonly performed in infants to rule out meningitis, is often not successful in the hands of inexperienced operators. Investigators conducted a study of 128 infants younger than 6 months. They compared traditional LP to LP preceded by…
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Correction for CSF protein in traumatic lumbar punctures

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Lumbar Puncture, medical procedures, Neurological diseases, Traumatology
More Tags – HPC updates, lumbar puncture, meningitis
Traumatic lumbar puncture (LP) is fairly common and occurs when the needle causes bleeding into the subarachnoid space. Introduction of peripheral red blood cells (RBCs) in cerebrospinal fluid (CSF) increases CSF protein levels, thereby complicating diagnosis of bacterial meningitis. This…
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Differences Between Lumbar Punctures in Children Vs Lumbar Punctures in Adults

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Lumbar Puncture, Medical General, medical procedures
More Tags – CSF Lactate Level, HPC updates, lumbar puncture, Pediatric Lumbar Puncture
Pediatric lumbar punctures can have much higher success rates when proper positioning and technique are emphasized. The position should be the lateral decubitus position with hips flexed, but the neck does not need to be flexed. The spinal cord ends…
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Essential to Administer Antibiotics Immediately if Bacterial Meningitis is Suspected

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Infections, Lumbar Puncture, Medical General, medical procedures, Neurological diseases
More Tags – Acute Bacterial Meningitis, CT scan, Guidelines, HPC updates, lumbar puncture
Prior to the revised Swedish lumbar puncture guideline, a CT scan was often performed prior to lumbar puncture when acute bacterial meningitis was suspected. Taking the time to perform a CT scan of the head before lumbar puncture delays treatment…
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