Nicole Barbera, MD, INOVA Fairfax Children’s Hospital 

Case: 11 yo F presenting with GTC, subsequently found to be hyponatremic and altered during ED course.

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Discussion

The work up for seizures can include many things or very little. This case drives home the point of checking electrolytes in a first time, afebrile seizure as this patient was subsequently found to be hyponatremic. As Drs. Agrawal and Combs mentioned, this is likely in the setting of her volume loss and excess of free water intake in relation to solute loss. While her seizure aborted without intervention, her sodium still begs to be corrected. But how? Given that she was overall stable, the majority of the group agreed on a normal saline bolus for slow correction.

As for the seizure work up, it was interesting that many of the fellows would obtain a Head CT, while the few of the attendings would. With a full return to baseline, it was felt that a Head CT was likely not indicated in this patient. When she later became altered, however, some mentioned they would consider it if her mental status did not improve with correction of her electrolytes. Dr. Patel also cited the importance of a thorough neurologic exam in patients such as these, as subtle findings (such as a small gait imbalance, slight dysmetria) can suggest intracranial pathology. Additionally, thinking beyond fluid imbalance, Dr. Agrawal raised the point that her hyponatremia may have been due to CSW, which also argues for head imaging.

Denouement

Patient was admitted to the PICU for frequent neurologic checks and management of hyponatremia.  She was found to be flu positive and presumed to have a hyponatremic seizure at home. She was safely discharged home without any further episodes

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