EM Quick Hits 25 Cerebral Venous Thrombosis, Diphenhydramine Alternatives, Abdominal Compartment Syndrome, Neonatal Constipation, Intubating Metabolic Acidosis

Topics in this EM Quick Hits podcast Justin Morgenstern on when to consider cerebral venous thrombosis (00:53) Maria Ivankovic on diphenhydramine alternatives (07:38) Brit Long on abdominal compartment syndrome (13:13) Sarah Reid on neonatal constipation  (19:37) Anand Swaminathan on intubating metabolic acidosis (27:40) Podcast production, editing and sound design by Anton Helman; voice editing by Raymond Cho Podcast content by Justin Morgenstern, Maria Ivankovic, Brit Long, Sarah Reid, Anand Swaminathan & Anton Helman  Written summary & blog post by Graham Mazereeuw, edited by Anton Helman Cite this podcast as: Helman, A. Morgenstern, J. Ivankovic, M. Long, B. Reid, S. Swaminathan, A. EM Quick Hits 25 - Cerebral Venous Thrombosis, Diphenhydramine Alternatives, Abdominal Compartment Syndrome, Neonatal Constipation, Intubating Metabolic Acidosis. Emergency Medicine Cases. January, 2021. https://emergencymedicinecases.com/em-quick-hits-january-2021/. Accessed [date]. When to Consider Cerebral Venous Thrombosis Presentation is nonspecific and highly variable: * Headache in nearly all patients (the only symptom in 25% of patients) * Other features: focal neurological deficit (40%), seizure (40%), encephalitis (rarely) Key demographics: * Young (39 years old on average) * Female (3x more commonly) * Usually at least one thrombotic risk factor Consider this diagnosis in 4 groups of patients: Group 1: severe or prolonged headache without a clear cause and with at least one thrombotic risk factor Group 2: thunderclap headache with a negative CT head Group 3: severe headache with stroke symptoms or neurological findings not clearly mapping to a vascular territory Group 4: intracranial hemorrhage without a classic bleeding pattern, particularly younger patients or those with thrombotic risk factors -MR venogram is gold standard; contrast CT venogram has good sensitivity (95%) -Treat the sequelae (ABCs, treat seizure, treat raised ICP) -Specific treatment is anticoagulation (even if intracranial hemorrhage!) in consultation with neurology/hematology -Full recovery = 80%; 30-day mortality = 5% Bottom line: CVT is the DVT of the brain; be on high alert for CVT in patients with thrombotic risk factors and atypical headache or stroke symptoms. Expand to view reference list * Tadi P, Behgam B, Baruffi S. Cerebral Venous Thrombosis. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459315/ Diphenhydramine Alternatives * First-generation antihistamines are “dirty drugs”: diphenhydramine and hydroxyzine have poor receptor selectivity, binding muscarinic, serotonergic, and alpha-adrenergic receptors, as well as cardiac potassium channels in addition to the H1 histamine receptor * First-generation antihistamines side effects: * CNS suppression, psychomotor impairment, delirium, coma, and death * QT prolongation and torsades de pointes * Recreational misuse ("Benadryl challenge" parties) * A therapeutic dose of diphenhydramine (50mg) can impair driving similarly to a 0.