{"id":1753,"date":"2017-08-30T21:10:26","date_gmt":"2017-08-31T01:10:26","guid":{"rendered":"https:\/\/www.roshreview.com\/?p=1753"},"modified":"2017-08-30T21:10:26","modified_gmt":"2017-08-31T01:10:26","slug":"ep-30-status-epilepticus-isoniazid-toxicity-sigmoid-volvulus-nsaid-overdose-hyponatremia-neonatal-seizures","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/ep-30-status-epilepticus-isoniazid-toxicity-sigmoid-volvulus-nsaid-overdose-hyponatremia-neonatal-seizures\/","title":{"rendered":"Podcast Ep 30: Status Epilepticus, Isoniazid Toxicity, Hyponatrem"},"content":{"rendered":"\n<figure class=\"wp-block-audio\"><audio controls src=\"https:\/\/media.blubrry.com\/thereveal\/s\/media.blubrry.com\/roshcast\/s\/content.blubrry.com\/roshcast\/Ep_30_Roshcast_Emergency_Board_Review.mp3\"><\/audio><\/figure>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\"><p>Only I can change my life. No one can do it for me.<\/p><cite>-Carol Burnett<\/cite><\/blockquote>\n\n\n\n<h6 class=\"wp-block-heading\">Welcome back to Episode 30! First, we must congratulate Sean for winning the trauma ring tone challenge by being the first to respond after the episode release. An honorable mention goes out to Nich and Dhinakar. Stay tuned for future contests and prizes!<\/h6>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\">Today\u2019s episode also marks the launch of a new partnership with the <a rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\" href=\"http:\/\/emclerkship.com\/\" target=\"_blank\">EM Clerkship podcast<\/a>. Going forward, we are going to occasionally focus episodes on a specific topic\u2014a topic that was recently covered by EM Clerkship. We will cover a few questions on that specific area and fill in the rest of the episode with the usual random assortment. &nbsp;You can listen to the podcasts in either order. &nbsp;Either start with Roshcast to see where you stand and then head over to EM clerkship for more detail\u2014or alternatively, start with EM clerkship to learn the nuts and bolts, and then head back here to test yourself. Any time we do these joint releases, we will plan to match our mid-week release with their release a few days earlier on Sunday. Hopefully you enjoy our new collaboration!<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Enough announcement. Let\u2019s get going with the rapid review!<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"201\" height=\"74\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview-2-e1475624722961.png\" alt=\"\" class=\"wp-image-818\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li> To diagnose <strong style=\"font-size: inherit\">Kawasaki disease<\/strong><span style=\"font-size: inherit\">, you must have a <\/span><strong style=\"font-size: inherit\">fever for five or more days<\/strong><span style=\"font-size: inherit\"> and <\/span><strong style=\"font-size: inherit\">four of the following<\/strong><span style=\"font-size: inherit\"> five criteria: <\/span><strong style=\"font-size: inherit\">bilateral bulbar conjunctival injection<\/strong><span style=\"font-size: inherit\">, <\/span><strong style=\"font-size: inherit\">oral mucous membrane changes<\/strong><span style=\"font-size: inherit\">, <\/span><strong style=\"font-size: inherit\">peripheral extremity changes<\/strong><span style=\"font-size: inherit\">, <\/span><strong style=\"font-size: inherit\">polymorphous rash<\/strong><span style=\"font-size: inherit\">, and <\/span><strong style=\"font-size: inherit\">cervical lymphadenopathy<\/strong><span style=\"font-size: inherit\">.<\/span> <\/li><li> <strong style=\"font-size: inherit\">Kawasaki disease<\/strong><span style=\"font-size: inherit\"> is <\/span><strong style=\"font-size: inherit\">treated<\/strong><span style=\"font-size: inherit\"> with <\/span><strong style=\"font-size: inherit\">IVIG and aspirin<\/strong><span style=\"font-size: inherit\">.<\/span> <\/li><li> <strong style=\"font-size: inherit\">Ocular findings<\/strong><span style=\"font-size: inherit\"> associated with <\/span><strong style=\"font-size: inherit\">Wernicke\u2019s encephalopathy<\/strong><span style=\"font-size: inherit\"> include <\/span><strong style=\"font-size: inherit\">nystagmus<\/strong><span style=\"font-size: inherit\">, <\/span><strong style=\"font-size: inherit\">lateral rectus palsy<\/strong><span style=\"font-size: inherit\">, and <\/span><strong style=\"font-size: inherit\">conjugate gaze palsies<\/strong><span style=\"font-size: inherit\">.<\/span> <\/li><li> When treating <strong style=\"font-size: inherit\">Wernicke encephalopathy<\/strong><span style=\"font-size: inherit\">, you should <\/span><strong style=\"font-size: inherit\">replace thiamine<\/strong><span style=\"font-size: inherit\"> <\/span><strong style=\"font-size: inherit\">before<\/strong><span style=\"font-size: inherit\"> repleting their <\/span><strong style=\"font-size: inherit\">glucose<\/strong><span style=\"font-size: inherit\">.<\/span> <\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Now onto this week&#8217;s podcast.<\/strong><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 1<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">You are caring for a 60 kg patient who has been seizing for 30 minutes. You have already administered 4 mg of IV lorazepam and 1200 mg of phenytoin without termination of seizure activity. Which of the following should most likely be your next step?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Administer another bolus of IV phenytoin<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Administer IV fosphenytoin <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Administer IV pentobarbital <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Administer IV sodium bicarbonate<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/2017\/08\/ep30-medications-for-status-epilepticus.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 2<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 33-year-old man presents with a seizure lasting for 5 minutes. EMS administered 2 mg of lorazepam with cessation of seizure activity. On presentation, the patient is confused. The patient\u2019s medication list includes metoprolol and isoniazid. During the evaluation, he has another seizure lasting for 10 minutes and then a third seizure lasting for another 10 minutes. What adjunctive therapy should be given?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Folic acid<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Phenobarbital<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Pyridoxine<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Sodium bicarbonate<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/2017\/08\/ep30-inh-toxicity.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 3<\/strong><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"400\" height=\"471\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/2017\/08\/ep30-sigmoid-volvulus.jpg\" alt=\"\" class=\"wp-image-1757\" srcset=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/2017\/08\/ep30-sigmoid-volvulus.jpg 400w, https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/2017\/08\/ep30-sigmoid-volvulus-255x300.jpg 255w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><\/figure><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">A 75-year-old nursing home patient presents with abdominal distension. Vital signs are normal and the patient is &#8220;nontoxic&#8221; appearing. An abdominal X-ray is obtained. What management is indicated?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Endoscopic detorsion<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Intravenous antibiotics<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Observation and reassessment<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Surgical resection<\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 4<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 26-year-old woman with a history of dysmenorrhea and depression presents to the ED after having a seizure witnessed by her husband. He reports finding her on the bedroom floor with an empty pill bottle. Which of the following non-steroidal anti-inflammatory (NSAIDs) medications did she most likely ingest?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Celecoxib<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Ibuprofen<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Mefenamic acid<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Rofecoxib<\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 5<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">An 8-month-old child presents to the emergency department having generalized tonic-clonic seizure activity. Her mother reports that she is bottle-fed and has been diluting her formula secondary to financial strains. Her serum sodium is found to be 120 mEq\/L. She weighs 8 kgs. She is actively seizing. What is the most appropriate dose of 3% hypertonic saline to administer the patient?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. 16 mL of 3% hypertonic saline <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. 4 mL of 3% hypertonic saline <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. 64 mL of 3% hypertonic saline <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. 80 mL of 3% hypertonic saline<\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span><strong>Question 6<\/strong><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A full-term 3-week-old girl is brought in by her parents who report that she has been \u201cacting funny\u201d for 2 hours. They noticed that she has been moving her lips nonstop. She was a full-term, normal, spontaneous vaginal delivery and has been feeding well with adequate wet diapers since hospital discharge. She is afebrile and vital signs are normal. The anterior fontanelle is flat, and red reflexes are present. Heart, lung, and abdominal exams are normal. Her neurologic exam is positive for root, suck, and Moro reflexes, upgoing Babinski reflexes, and rhythmic lip-smacking movements. What is the most appropriate next step to take with this baby?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Administer phenobarbital<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Initiate EEG monitoring<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Perform a CT scan of the brain<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Provide reassurance that this is normal behavior<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/2017\/08\/ep30-neonatal-seizures.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"201\" height=\"74\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview-2-e1475624722961.png\" alt=\"\" class=\"wp-image-818\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Status epilepticus<\/strong> is <strong>defined<\/strong> as <strong>2 or more continuous seizures without full recovery<\/strong> or <strong>continuous seizure activity for greater than 5 minutes<\/strong>.<\/li><li><strong>Benzodiazepines<\/strong> are the <strong>first-line agents<\/strong> for <strong>status epilepticus<\/strong>. &nbsp;<strong>Midazolam<\/strong> has the <strong>fastest onset<\/strong>,&nbsp;but <strong>lorazepam<\/strong> has a <strong>longer half-life<\/strong>.<\/li><li><strong>Second-line agents<\/strong> for <strong>status epilepticus<\/strong> include <strong>phenytoin<\/strong>, <strong>fosphenytoin<\/strong>, <strong>valproic acid<\/strong>, <strong>phenobarbital<\/strong>, or <strong>levetiracetam<\/strong>. <strong>Fosphenytoin<\/strong> is <strong>preferred<\/strong> as it can be given more quickly.<\/li><li><strong>Third-line agents<\/strong> for <strong>status epilepticus<\/strong> include <strong>pentobarbital<\/strong> and <strong>propofol<\/strong> along with <strong>likely<\/strong> <strong>intubation<\/strong>.<\/li><li>All <strong>seizing<\/strong> patients need to have their <strong>blood glucose<\/strong> checked.<\/li><li>In patients on <strong>INH<\/strong> having <strong>seizures<\/strong>, <strong>pyridoxine<\/strong> should be administered.<\/li><li>For <strong>sigmoid volvulus<\/strong>, the treatment of choice is <strong>endoscopic detorsion<\/strong>, typically a <strong>flexible sigmoidoscopy<\/strong>.<\/li><li>On a <strong>barium enema<\/strong> of a patient with <strong>sigmoid volvulus<\/strong>, the classic finding is a <strong>bird\u2019s beak appearance<\/strong>.<\/li><li><strong>Mefenamic<\/strong> <strong>acid<\/strong> is an <strong>NSAID<\/strong> given for <strong>menstrual pain<\/strong>. <strong>Overdose<\/strong> can cause <strong>seizures 2\u20137 hours after ingestion<\/strong>. &nbsp;<strong>Treatment<\/strong> is with <strong>benzodiazepines<\/strong>.<\/li><li>For <strong>seizures<\/strong> related to <strong>hyponatremia<\/strong>,<strong> 3% hypertonic saline<\/strong> at <strong>2 mL\/kg<\/strong> should be given with a <strong>max of 100 mL over 10\u201360 minutes<\/strong>.<\/li><li><strong>Neonatal seizures<\/strong> are more likely to be <strong>focal<\/strong> than tonic-clonic. &nbsp;Look for signs like <strong>lip smacking<\/strong>, <strong>eye deviation<\/strong>, <strong>staring<\/strong>, <strong>rhythmic blinking<\/strong>, and <strong>bicycling<\/strong> movements.<\/li><li><strong>Phenobarbital<\/strong> is the drug of choice for <strong>neonatal seizures<\/strong>.<\/li><li><strong>First neonatal seizures<\/strong> require a <strong>full septic workup<\/strong>. <strong>Empiric antibiotics<\/strong> should be given.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">That wraps up Episode 30. Don\u2019t forget to follow us on Twitter at <a href=\"http:\/\/twitter.com\/roshcast\">@Roshcast<\/a> and <a href=\"http:\/\/twitter.com\/roshreview\">@RoshReview<\/a>. We can also be reached by email at <a href=\"mailto:roshcast@roshreview.com\">roshcast@roshreview.com<\/a>. Send over any feedback, corrections, or suggestions. You can also help us <strong>pick questions for the podcast<\/strong> by identifying ones you would like us to review. To do so, <strong>write \u201cRoshcast\u201d in the submit feedback box<\/strong> as you go through the question bank.&nbsp;And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about Roshcast.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Until next time,<br>Jeff and Nachi<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Only I can change my life. No one can do it for me. -Carol Burnett Welcome back to Episode 30! First, we must congratulate Sean for winning the trauma ring tone challenge by being the first to respond after the episode release. An honorable mention goes out to Nich and Dhinakar. Stay tuned for future <a href=\"https:\/\/www.roshreview.com\/blog\/ep-30-status-epilepticus-isoniazid-toxicity-sigmoid-volvulus-nsaid-overdose-hyponatremia-neonatal-seizures\/\">read more&#8230;<\/a><\/p>\n","protected":false},"author":11,"featured_media":851,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[2025,1999],"tags":[2164,2196,2219,2233,2239,2248,2358,2428,2429,2459,2597,2630,2653,2663,2682,2698,2713,2729,2745,2838,2846,2883,2896,2907,2912,2926,2948,2963,2971,2981,3018,3022,3033,3107,3110,3113,3130,3141,3178,3265,3274,3299,3300,3339,3383,3421,3472,3518,3523,3536,3576,3577,3607,3645,3669,3730,3776],"coauthors":[],"class_list":["post-1753","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-emergency-medicine","category-podcast","tag-antibiotics","tag-aspirin","tag-barium-enema","tag-benzodiazepine","tag-bicycling","tag-birds-beak","tag-cervical-lymphadenopathy","tag-conjugate-gaze-palsy","tag-conjunctival-injection","tag-critical-care","tag-endoscopic-detorsion","tag-eye-deviation","tag-fever-for-five-days","tag-flexible-sigmoidoscopy","tag-fosphenytoin","tag-gastroenterology","tag-gi","tag-glucose","tag-half-life","tag-hypertonic-saline","tag-hyponatremia","tag-inh","tag-intubation","tag-isoniazid","tag-ivig","tag-kawasaki-disease","tag-lateral-rectus-palsy","tag-levetiracetam","tag-lip-smacking","tag-lorazepam","tag-mefenamic-acid","tag-menstrual-pain","tag-midazolam","tag-neonatal-seizure","tag-neonatology","tag-neurology","tag-nsaid","tag-nystagmus","tag-overdose","tag-pediatrics","tag-pentobarbital","tag-phenobarbital","tag-phenytoin","tag-polymorphous-rash","tag-propofol","tag-pyridoxine","tag-rhythmic-blinking","tag-seizure","tag-sepsis","tag-sigmoid-volvulus","tag-staring","tag-status-epilepticus","tag-surgery","tag-thiamine","tag-toxicology","tag-valproic-acid","tag-wernickes-encephalopathy"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v21.7 (Yoast SEO v26.6) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Podcast Ep 30: Status Epilepticus, Isoniazid Toxicity, Hyponatrem | RoshReview.com<\/title>\n<meta name=\"description\" content=\"Welcome to RoshCast (Ep. 30), the first question and answer style emergency medicine podcast. 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