Em basic- hyponatremia

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EM Basic- Hyponatremia

(This document doesn’t reflect the views or opinions of the Department of Defense, the US Army, or the Fort Hood post command, © 2012 EM Basic, Steve Carroll DO. May freely distribute with proper attribution)

Hyponatremia- serum sodium less than 135 meq/L

-First decision point- seizing, obtunded, or altered mental status?

-If yes- go to critical care section

-If no- then DO NOTHING (well, not quite nothing but don’t try to start correcting the patient’s sodium level in the ED)

Symptoms- Can be vague and non-specfic

-Weakness, fatigue, headache, confusion, etc.

-May be relatively asymptomatic and hyponatermia discovered

during workup for something else

Usual patient- older patient with “weakness” who is alert and oriented with a sodium of 130 meq/L

-This patient accounts for the vast majority of ED patients with hyponatermia

Management- alert and oriented patient

-First step- water restrict

-Write a nursing order to make patient NPO

-Tell patient that they have to be water restricted

-Second step- investigate for whether this is acute or chronic

-Look back in the medical record

-If patient has 3 sets of labs over past 3 months with same

sodium level then not that worried

-May be possible to discharge that patient if they don’t need admission for something else

-If this is new for the patient then go to the next step

-Third step- investigate for possible cause of hyponatermia

-Medications are a common cause

-Hydrochlorothiazide and SSRIs are common causes

-SSRIs- Prozac (fluxoetine), Zoloft (sertraline)

-MDMA (street drug “ecstasy) also a cause

-Inappropriate secretion of antiduretic hormone (ADH) leads to increase free water retention and dilution of sodium level

Causes of hyponatremia (continued)
-Volume losses

-Vomiting and diarrhea

-“Leaky fluid states”

-Severe liver disease, congestive heart failure (CHF)

-Renal failure

-Endocrine causes

-Hypothyroidism and adrenal insufficiency

-“Beer potomania”

-Excessive alcohol consumption- alcohols lack electrolytes so drinking large amounts without eating solid food can deplete sodium levels


-Lung cancer is notorious for causing hyponatremia

-Ask about red flags (unexplained weight loss, night

sweats, unexplained bone or muscle pain, new back pain in an elderly patient)
Fourth Step- Admit the patient and DO NOTHING

***PEARL***- Correcting the sodium too rapidly can lead to Central Pontine Myelinolysis which can cause permanent neurological damage and death
-Don’t try to correct sodium level in the ED- JUST WATER RESTRICT!

-Resist the urge to gently hydrate with normal saline- even this can raise the patient’s sodium too fast

-Inpatient team may want urine electrolytes, osoms, etc.
Hyponatremia critical care- patient is seizing, altered or obtunded
-Much different patient

-Hypertonic saline to correct sodium until they stop seizing

-Only need to raise sodium about 3-5 points to do this

-Hypertonic saline

-3 mls per kilogram IV with theoretical max of 100 mls

-Rapid sequential boluses over max 10 minutes or until

seizures stop

-Central access preferred but can give it through a GOOD peripheral IV (AC peripheral, not small hand vein)

Hyponatremia critical care (continued)

-Sodium Bicarbonate

-A substitute for hypertonic saline in a pinch

-Equivalent to about 11% hypertonic saline

-One amp usually is 50 mls but more Na than 3%

-One amp approx. 210 mls of 3% hypertonic saline

-Push this slower since more concentrated than 3%

-Give Ativan (lorazepam) or Valium (diazepam) in case hyponatremia is not causing seizures and it is a primary seizure disorder instead

***PEARL- If you have a patient with seizures that isn’t responding to benzos, consider hyponatremia as a cause***
-Patient with low sodium (115) but just a little altered and not seizing

-Give 3% hypertonic saline- 100 mls over one hour

-Will raise sodium by 2 points

-How much to correct the sodium safely?

-Rule of Sixes (borrowed from EmCrit, borrowed from review article)

-Six points for Severe Symptoms in then Stop

-Once you correct 6 points in 6 hours, stop until the 24 hour mark to avoid overcorrection

-Six a day makes Sense for Safety

-More for chronic hyponatremia- don’t correct more than 6

points over a 24 hour period

Contact- steve@embasic.org Twitter- @embasic

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