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.

 Physical Exam

  • BP 220/107 | Pulse 97 | Resp 16 | SpO2 98%
  • Neuro: Alert. Moves all extremities. +language barrier

Differential Diagnosis:

  • CVA / ICH 
  • arrhythmia
  • seizure
  • Tox/metabolic

Initial Orders:

  • 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.

Further history:

  • 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. 

Teaching Points:

  • 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!