EM Quick Hits 46 – Wilderness Medicine, Bowel Prep Hyponatremia, Non-Convulsive Status Epilepticus, Morel Lavallee Lesions, Pacemaker ECGs, Loans vs Investing

Topics in this EM Quick Hits podcast

Justin Hensley & Aaron Billin on wilderness medicine (0:38)

Elisha Targonsky on bowel prep hyponatremia (Best of University of Toronto EM) (14:23)

Brit Long on identification of non-convulsive status epilepticus (21:18)

Andrew Petrosoniak on Morel Lavallee lesions (29:24)

Jess McLaren on approach to the ECG in the paced patient (36:35)

Matt Poyner on loan repayment vs investing (41:22)

Podcast production, editing and sound design by Anton Helman

Written summary & blog post by Hanna Jalali, Andrew Petrosoniak and Brit Long.

Edited by Anton Helman, February 2023

Cite this podcast as: Helman, A. Hensley, J. Billin, A. Targonsky, E. Long, B. Petrosoniak, A. McLaren, J. Poyner, M. EM Quick Hits 46 - Wilderness Medicine, Bowel Prep Hyponatremia, Non-Convulsive Status Epilepticus, Morel Lavallee Lesions, Pacemaker ECGs, Loans vs Investing. Emergency Medicine Cases. February, 2023. https://emergencymedicinecases.com/em-quick-hits-february-2023/. Accessed May 30, 2024.

Bowel prep hyponatremia

Best of University of Toronto EM

* Severe hyponatremia causing coma and/or seizure after bowel prep such as polyethylene glycol for colonoscopy has been reported in the literature.

* The incident of hyponatremia and elevated ADH levels is up to 7.5% in patients post-colonoscopy.

* Causes are multifactorial:

* Stress from procedure/prep causing non-osmotic ADH release, water retention

* GI volume losses

* Dietary restriction, low solute intake

* Massive free water intake, dilutional hyponatremia

* Risk factors:

* Large volume intake over short time

* More frequent in women

* Concomitant use of thiazide diuretics

* Concomitant hypothyroidism

* Treatment of severe hyponatremia with coma/seizure includes hypertonic saline, given as a bolus of 100-150mL of fluid over 5-10 minutes (repeat x 1-2 prn), stopping all other IV fluids, insertion of foley catheter to monitor urine output, frequent checks of serum electrolytes being careful not to increase serum sodium by more than 6mmol/L over 6 hours for severely symptomatic patients and aiming to increase sodium by 4-6mmol/L over first 2 hours, and no more than 10mmol/L over 24 hours

* Resist treatment in patients with mildly impaired mental status, or chronic hyponatremia as rapid correction can lead to osmotic demyelination syndrome.

Episode 60 Emergency Management of Hyponatremia

Expand to view reference list

* Adrogué HJ, Tucker BM, Madias NE. Diagnosis and Management of Hyponatremia: A Review. JAMA. 2022 Jul 19;328(3):280-291.

* Windpessl, M., Schwarz, C. & Wallner, M. “Bowel prep hyponatremia“ – a state of acute water intoxication facilitated by low dietary solute intake: case report and literature review. BMC Nephrol 18, 54 (2017).

* Reumkens A, van der Zander Q, Winkens B, Bogie R, Bakker CM, Sanduleanu S, Masclee AAM. Electrolyte disturbances after bowel preparation for colonoscopy: Systematic review and meta-analysis. Dig Endosc. 2022 Jul;34(5):913-926.

* Costelha J,