Hypernatremia & Hyponatremia Tutorial

Refer to ED lecture series and self directed workbooks Hyponatremia Which of the following is not a cause of hyponatremia? Hyperglycemia SIADH/water intoxication Diuretic Use Odema/CHF/CRF Trauma Refer to ED lecture series and self directed workbooks

Hyperglycaemia Which of the following is not a cause of hyponatremia? Hyperglycemia Pseudohyponatraemia. As glucose levels rise the osmolarity increases causing water to shift out of cells. Increased water in circulation dilutes the sodium. SIADH/water intoxication Diuretic Use Odema/CHF/CRF Press the other options to learn more or select next Trauma Next Refer to ED lecture series and self directed workbooks

SIADH/Water Intoxication Which of the following is not a cause of hyponatremia? Inappropriate levels of water in the system cause a dilutional effect for sodium Hyperglycemia SIADH/water intoxication Diuretic Use Odema/CHF/CRF Press the other options to learn more or select next Trauma Next Refer to ED lecture series and self directed workbooks

Diuretic Use Which of the following is not a cause of hyponatremia? Hyperglycemia The most common cause of hyponatremia is diuretic use with low salt diet in a patient with CHF SIADH/water intoxication Diuretic Use Odema/CHF/CRF Press the other options to learn more or select next Trauma Next Refer to ED lecture series and self directed workbooks

Odema/CHF/CRF Which of the following is not a cause of hyponatremia? Hyperglycemia The most common cause of hyponatremia is diuretic use with low salt diet in a patient with CHF SIADH/water intoxication Diuretic Use Odema/CHF/CRF Press the other options to learn more or select next Trauma Next Refer to ED lecture series and self directed workbooks

Trauma Which of the following is not a cause of hyponatremia? Next Hyperglycemia SIADH/water intoxication Diuretic Use Odema/CHF/CRF Press the other options to learn more or select next Trauma Next Refer to ED lecture series and self directed workbooks

Hyponatreamia Most patients are stable and require no emergency therapy Patient who have a sever hyponatreamia and are symptomatic do require emergency treatment.

Hyponatreamia How do you decide if a patient if a patient is dehydrated or just ‘wasting’ sodium? Serum Na Urine Na & Cl Serum glucose

Press the other options to learn more or select next Serum Sodium How do you decide if a patient if a patient is dehydrated or just ‘wasting’ sodium? Serum Na In a dehydrated patient the sodium values tend to be elevated as the body becomes deficient of free water. Low serum sodium in the presence of markedly elevated potassium and glucose may indicate endocrine disease such as Addison’s. Some endocrine diseases cause ‘sodium wasting’. Urine Na & Cl Serum glucose Press the other options to learn more or select next Next

Urine Sodium & Chloride How do you decide if a patient if a patient is dehydrated or just ‘wasting’ sodium? If a patient is wasting sodium it will be evident in the urine. Na below 20 = dehydration Na above 20 = Cl or Na wasting If a patient is hyponatreamic they should have hyponatreamic urine. If not then it is an indication that there maybe a kidney problem or an neurological issue. Serum Na Urine Na & Cl Serum glucose Press the other options to learn more or select next Next

Serum Glucose How do you decide if a patient if a patient is dehydrated or just ‘wasting’ sodium? Serum Na Low sodium vales in the presence of hyperglycemia need to be “corrected”. This casued by water shitfing from intracellular to extracellular compartment s in the presence of high glucose. This condition is called translational hyponatremia and no specific treatment is indicated, because the sodium concentration will return to normal once the plasma glucose concentration is lowered. Urine Na & Cl Serum glucose Press the other options to learn more or select next Next

Case 1 A 18yo female presents with a seizure after dancing all night. She has a sodium of 105. Why? Dehydration Drugs DKA

Dehydration A 18yo female presents with a seizure after dancing all night. She has a sodium of 105. Why? Dehydration is often associated with high levels of sodium as the body becomes deficient of free water. Dehydration Drugs DKA Press the other options to Learn more or select next Next

Drugs A 18yo female presents with a seizure after dancing all night. She has a sodium of 105. Why? Complications are more common in females. Think about ecstasy. Ecstasy stimulates ADH causing water retention. Also stimulates sodium secretion into the bowel. Dehydration Drugs DKA Press the other options to Learn more or select next Next

DKA A 18yo female presents with a seizure after dancing all night. She has a sodium of 105. Why? Measuring the plasma glucose will answer this question, also a VBG would be useful. Dehydration Drugs DKA Press the other options to Learn more or select next Next

Case 2 A runner seizes at 24km and has a normal body temperature. Hyponatremia or hypernatremia? Hyponatremia Hypernatremia

Hyponatremia A runner seizes at 24km and has a normal body temperature. Hyponatremia or hypernatremia? A true serum sodium will be required in this case along with a history of hydration during the event. New runners or runner not attuned to temperature have a tendency to overhydrate leading to sodium dilution. They begin to feel dizzy nauseated which can then lead to seizures. Look for normal skin turgor and colour and edema in the extremities. Hyponatremia Hypernatremia Press the other options to Learn more or select next Next

Hypernatremia A runner seizes at 24km and has a normal body temperature. Hyponatremia or hypernatremia? Hypernatremia associated with exercise induced dysnatremia and is prevalent amounts long distance runners although generally presenting with an above normal body temperature. A true serum sodium will be required in this case along with a history of hydration during the event. Hyponatremia Hypernatremia Press the other options to Learn more or select next Next

Treatment How quickly can you raise someone’s sodium? 10-12 mmol/L/day

Treatment – 10-12 mmol/L/day How quickly can you raise someone’s sodium? Correct! Never change serum Na levels by more than 10-12 mmol/L/day otherwise you could cause Central Pointine Myelinosis. Rapid correction of serum sodium dramatically increases the osmotic potential drawing water out of the cellular space causing cell death. Brain cells are at high risk. 10-12 mmol/L/day 15-20 mmol/L/day 20-25 mmol/L/day Press the other options to learn more or select next Next

Treatment – 15-20 mmol/L/day How quickly can you raise someone’s sodium? Incorrect! Never change serum Na levels by more than 10-12 mmol/L/day otherwise you could cause Central Pointine Myelinosis. Rapid correction of serum sodium dramatically increases the osmotic potential drawing water out of the cellular space causing cell death. Brain cells are at high risk. 10-12 mmol/L/day 15-20 mmol/L/day 20-25 mmol/L/day Press the other options to learn more or select next Next

Treatment – 20-25 mmol/L/day How quickly can you raise someone’s sodium? Incorrect! Never change serum Na levels by more than 10-12 mmol/L/day otherwise you could cause Central Pointine Myelinosis. Rapid correction of serum sodium dramatically increases the osmotic potential drawing water out of the cellular space causing cell death. Brain cells are at high risk. 10-12 mmol/L/day 15-20 mmol/L/day 20-25 mmol/L/day Press the other options to learn more or select next Next

Hypertonic Saline Next Indications (if only previously normal) Seizures Coma Focal findings In order to use, serum sodium is usually 100 – 110 mmol/L What concentration? 3% At what rate (for adults)? 1st bolus 100 cc over 10 minutes, if no response 2nd bolus 100 cc over next 50 minutes For how long? Treat for 1 hour Should increase serum levels by about 3 mmol/L, then continue treatment over the next 24 hours, but no more than 10-12 mmol/L/day correction. Next

Refer to ED lecture series and self directed workbooks Hypernatremia Which of the following is not a cause of hypernatremia? Dehydration Diuretic Therapy Diabetes SIADH Refer to ED lecture series and self directed workbooks

Dehydration Which of the following is not a cause of hypernatremia? Dehydration/Hypovolmeia is the most common cause. Usually due to inadequate intake or excessive loss associated with total body sodium depletion. Common in elderly or disabled. Other causes include: UTI, sever burns, sever watery diarrhea. Dehydration Diuretic Therapy Diabetes SIADH Press the other options to learn more or select next Next Refer to ED lecture series and self directed workbooks

Diuretic Therapy Which of the following is not a cause of hypernatremia? Hypernatremia secondary to diuretic therapy is common with increasing age (>65 years) Dehydration Diuretic Therapy Diabetes SIADH Press the other options to learn more or select next Next Refer to ED lecture series and self directed workbooks

Diabetes Which of the following is not a cause of hypernatremia? Next Excessive excretion of water from the kidneys caused by diabetes insipidus; caused from inadequate production or impaired response to vasopressin. Patients with uncontrolled diabetes melitus may present with osmotic diuresis due to glycouria resulting in hypernatremia. Dehydration Diuretic Therapy Diabetes Press the other options to learn more or select next Next Refer to ED lecture series and self directed workbooks

Hypernatremia Which of the following is not a cause of hypernatremia? SIADH causes a euvolemic hyponatremia. The patient will have an increased total body water with near-normal total body sodium. Dehydration Diuretic Therapy Diabetes SIADH Press the other options to learn more or select next Next Refer to ED lecture series and self directed workbooks

“Worst” electrolyte abnormality in terms of prognosis Hypernatremia “Worst” electrolyte abnormality in terms of prognosis Often due to altered mental status (especially in the elderly) Dramatically increases mortality for any coexisting disease

Case 3 80 year old male BIBA. He is abtunded, has poor BP of 90/50, serum Na 178 mmol/L What is the best initial fluid? Normal Saline ½ Normal Saline Dehydration Distalled H2O 3% hypertonic saline

Press the other options to learn more or select next Normal Saline 80 year old male BIBA. He is obtunded, has poor BP of 90/50, serum Na 178 mmol/L What is the best initial fluid? CORRECT! Hypotension supersedes sodium values. Correct the volume deficiency first. Normal saline has a lower salt concentration than the patient. Lowering the sodium too quickly may be fatal. Once nomovolaemic but symptomatic change to 5% Dextrose Normal saline ½ Normal saline Dehydration Distilled H20 3% hypertonic saline Press the other options to learn more or select next Next

Press the other options to learn more or select next ½ Normal Saline 80 year old male BIBA. He is obtunded, has poor BP of 90/50, serum Na 178 mmol/L What is the best initial fluid? Hypotension supersedes sodium values. Correct the volume deficiency first. Lowering the sodium too quickly may be fatal. Secure the ABC’s Normal saline ½ Normal saline Dehydration Distilled H20 3% hypertonic saline Press the other options to learn more or select next Next

Press the other options to learn more or select next Distilled H2O 80 year old male BIBA. He is obtunded, has poor BP of 90/50, serum Na 178 mmol/L What is the best initial fluid? Free water is often used to correct water deficiency, but not the best choice for this case. IV water must be given with dextrose or saline infusion solutions. Rapid overcorrection of serum sodium is potentially very dangerous due to cerebral edema. Normal saline ½ Normal saline Dehydration Distilled H20 3% hypertonic saline Press the other options to learn more or select next Next

Press the other options to learn more or select next 3% hypertonic Saline 80 year old male BIBA. He is obtunded, has poor BP of 90/50, serum Na 178 mmol/L What is the best initial fluid? Hypotension supersedes sodium values. Correct the volume deficiency first. Lowering the sodium too quickly may be fatal. Secure the ABC’s Normal saline ½ Normal saline Dehydration Distilled H20 3% hypertonic saline Press the other options to learn more or select next Next

Treatment Same as hyponatremia Correct by no more than 0.5 mmol/hour 10-12 mmol/day

Summary Secure the ABC’s Hyponatremia = 0.5mmol/hr or 10-12mmol/day Hypertonic saline only for emergencies Hypernatremia = dehydration Treat hypotension over hypernatremia.

Resources Journal of the American Society of Nephrology (http://jasn.asnjournals.org/content/20/2/251.full ) Medscape (http://emedicine.medscape.com/article/766479-overview ) USCEssentials 2009-04 ‘KypoNa/HyperNa ’ Dr Corey Slovis https://www.clinicalkey.com.au/topics/nephrology/hypernatremia.html Sodium Disorders In The Emergency Department: A Review Of Hyponatremia and Hypernatremia – Emergency Medicine Practice October 2012 Volume 14, Number 10

Further reading