CPEN Neurological Emergencies 5 — Questions and Answers
Question 1: A 1-month-old presents with seizures, lethargy, and a sodium of 118 mEq/L after breastfeeding with excessive water supplementation. The SAFEST correction rate for hyponatremia is:
- Correct sodium by 20 mEq/L in the first hour
- Correct sodium by no more than 1–2 mEq/L per hour, max 10–12 mEq/L per day (Correct answer)
- Rapid correction with 3% NaCl over 30 minutes to 135 mEq/L
- Correct only with free fluid restriction, no sodium supplementation
Correct answer: Correct sodium by no more than 1–2 mEq/L per hour, max 10–12 mEq/L per day
Overly rapid correction of hyponatremia risks osmotic demyelination; the safe rate is ≤1–2 mEq/L/hr, not exceeding 10–12 mEq/L in 24 hours (except for acute symptomatic seizures).
Question 2: Which antiepileptic drug is FIRST-LINE for infantile spasms (West syndrome)?
- Phenobarbital
- ACTH (adrenocorticotropic hormone) (Correct answer)
- Levetiracetam
- Carbamazepine
Correct answer: ACTH (adrenocorticotropic hormone)
ACTH is the first-line treatment for infantile spasms and has shown superior efficacy in reducing spasms and improving EEG in West syndrome.
Question 3: A 7-year-old presents 4 hours after last seizure with persistent confusion and no return to baseline. The MOST appropriate diagnosis to rule out immediately is:
- Simple febrile seizure
- Post-ictal state (normal)
- Nonconvulsive status epilepticus (NCSE) (Correct answer)
- Syncope with prolonged recovery
Correct answer: Nonconvulsive status epilepticus (NCSE)
Persistent altered consciousness beyond the expected post-ictal period requires EEG to exclude nonconvulsive status epilepticus, which is treatable but easily missed.
Question 4: In a pediatric patient with suspected spinal cord injury without radiographic abnormality (SCIWORA), which imaging modality is MOST sensitive for diagnosis?
- Plain X-rays of the spine
- CT spine with reconstruction
- MRI of the spine (Correct answer)
- Bone scan
Correct answer: MRI of the spine
MRI is the gold standard for SCIWORA, as it visualizes cord edema, hemorrhage, and ligamentous injury not seen on CT or X-ray.
Question 5: A 10-year-old post-cardiac arrest is receiving targeted temperature management. The target core temperature range is:
- 33–34°C for 12 hours only
- 32–34°C for 24–48 hours
- 36–37.5°C (normothermia) for 72 hours (Correct answer)
- 30–32°C for 6 hours
Correct answer: 36–37.5°C (normothermia) for 72 hours
Current pediatric post-arrest guidelines support targeted temperature management at 36–37.5°C (normothermia prevention of fever) for at least 72 hours.
Question 6: A 5-year-old with meningococcal meningitis develops purpuric lesions spreading rapidly across the trunk and extremities. The MOST urgent intervention is:
- Await blood culture results before starting antibiotics
- Administer IV ceftriaxone immediately without delay (Correct answer)
- Perform lumbar puncture before antibiotics to confirm diagnosis
- Apply topical corticosteroids to the rash
Correct answer: Administer IV ceftriaxone immediately without delay
Rapidly spreading purpura indicates meningococcemia; IV ceftriaxone must be given immediately as delay worsens outcome even if LP has not yet been performed.
Question 7: Which clinical feature helps DIFFERENTIATE a complex febrile seizure from simple febrile seizure?
- Age younger than 18 months
- Fever greater than 40°C
- Seizure lasting more than 15 minutes or focal features (Correct answer)
- Postictal drowsiness lasting 15 minutes
Correct answer: Seizure lasting more than 15 minutes or focal features
Complex febrile seizures are defined by duration >15 minutes, focal onset, or recurrence within 24 hours, distinguishing them from simple generalized febrile seizures.
CPEN Neurological Emergencies 5
A 1-month-old presents with seizures, lethargy, and a sodium of 118 mEq/L after breastfeeding with excessive water supplementation.
The SAFEST correction rate for hyponatremia is: