Tuesday - Critical Cases Review!
HPI:A 58 y/o female with Hx diabetes, hyperlipidemia, and HTN brought into the ED by EMS after being found down at home.
- Per EMS, patient collapsed with ?shaking activity
- Noted to have recently been started on oxcarbazepine (Trileptal) for unknown reasons.
- BP 220/107 | Pulse 97 | Resp 16 | SpO2 98%
- Neuro: Alert. Moves all extremities. +language barrier
- CVA / ICH
- Monitor, PIV access, continuous ECG monitoring Accu check
- Labs: CBC, BMP, hsTrop, ECG, CT head non-contrast
Further history from son:
- Pt found unconscious on the floor with her arms and legs tense and her tongue retracted into her mouth.
Workup results and clinical course:
- Presumptive diagnosis: seizure possibly from noncompliance with oxcarbazepine
- CT non-contrast head: acute subdural hematoma BMP: Na 118
- Nicardepene gtt for BP management
- IV Keppra load
- Hypertonic saline bolus
- Admitted to trauma ICU with neurosurgery and nephrology consulted
- Required intubation for depressed mental status and eventually discharged with trach.
- Required hypertonic saline infusion to achieve normonatremia.
- Pt had been started on oxcarbazepine for mood disorder and had no history of seizures
- Oxcarbazepine was stopped in setting of outpatient labs demonstrating hyponatremia.
- Hyponatremia should be on the ddx for seizure/encephalopathy
- Oxcarbazepine may cause hyponatremia in 1-10% of patients
- Do not anchor on epilepsy as cause of seizures!