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Case 1- M.H. (Chico State U., California)

Case 1- M.H. (Chico State U., California). 18M presents after 3 grand-mal seizures after collapsing during fraternity hazing ritual Pledges were forced to do push-ups/exercises for hours in raw sewage that had leaked into basement of fraternity

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Case 1- M.H. (Chico State U., California)

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  1. Case 1- M.H. (Chico State U., California) • 18M presents after 3 grand-mal seizures after collapsing during fraternity hazing ritual • Pledges were forced to do push-ups/exercises for hours in raw sewage that had leaked into basement of fraternity • Kept drinking from 5 gallon jug of water which was continuously refilled • Vomitted and urinated on themselves

  2. Case 1 • Initial vitals: • 120/60 70 20 98% RA T=37.5 • Clinically euvolemic • Confused

  3. Case 1 • Initial labs • Na = 110, urine Na <10, • serum osmol = 270 • How would you treat?

  4. Hyponatremia Matthew Harrington Sultana Qureshi, R2 Lab Rounds Feb 8, 2007

  5. HypoNa Basics • HypoNa is a symptom of disease • Na <135 mEq/L • Most common lyte abn in hospital pts • Incidence 1%, increases with age • Acute, symptomatic cases, mortality up to 18%

  6. Quick Physiology Review • 3 fluid compartments • (2/3) ICF & (1/3)ECF (InterstitialF + IVF) • Na concentration governs movement of water across these spaces Body tightly maintains serum osmolality within 1-2% of 275-295 mosmol/kg • Na balance = Renin-angiotensin • Water balance = ADH

  7. Quick Physiology Review • Hypotension or low ECF  renin release from JGAangiotensin II  aldosterone production Na reabsorption and K excretion • Incr serum osmolality, Decr. BP or volume  ADH release from post. Pituitary • More sens to hypovolemia than low osmol.

  8. Clinical Features • Absolute Na level not as important as RATE OF DECLINE

  9. Symptoms Thanks to Moritz!

  10. Approach • Classify Osmolality and Volume status • Osmolality • Hyperosmolar – excess solutes (ie glucose) draw water into ECF diluting Na • Iso-osmolar – psuedohyponatremia • Hypo-osmolar (MOST COMMON) – excess water in relation to Na stores (may be incr, decr or n) – categorized by volume status

  11. Hypo-osmolar HypoNa • Hypervolemic • CHF, ARF, CRF, cirrhosis/ascites, pregnancy • Euvolemic • SIADH, adrenal insuff, hypothyroid, psychogenic polydipsia, sports • Hypovolemic • Diuretics, diarrhea, sweating, third-spacing, salt-wasting nephropathy

  12. CNS disease Brain tumor infarction injury abscess Meningitis/  Encephalitis  Pulmonary disease Pneumonia Tuberculosis Lung abscess Pulmonary aspergillosis  Drugs Exogenous vasopressin (enuresis)   Diuretics   Chlorpropamide   Vincristine   Thioridazine   Cyclophosphamide Causes of SIADH

  13. Most common is hypo-osmolar hyponatremia

  14. Case 2 • 75F – weak and dizzy x 1 week, falls at home presenting with hip # • PMHx – Hyperlipidemia, HTN, chronic diarrhea NYD • Meds: HCTZ, lipitor • Vitals: 85, 110/70, 14, 95% RA

  15. Case 2 • Labs: Na- 112, K-4.5, Cl- 82, CO2 -12 • Serum osmol – 240 • Urine osmol – 300 • Urine Na - <10 • Cause of HypoNa? • How would you treat?

  16. Management • Guided by severity of symptoms and acuity • Chronic • Gradual correction <0.5 mEq/L/hr • Acute/Symptomatic • Tolerate faster correction up to 1-2 mEq/l/hr

  17. Management • CNS symptoms/seizures • Correct with hypertonic saline (3%) until resolved • usually need to increase Na by 4-6 mEq/L only • Then correct 8-10mEq/L/day • Formula • (Desired [Na+] – measured [Na+] ) x 0.6Wt(kg) = mEq Na+ req’d • Eg (117-112) X 0.6(70) = 210 mEq

  18. Case 2 (continued) • It’s July 1st and the Ortho R1 decides to fluid resuscitate her with NS 2L bolus, then runs it at 200cc/hr • Pt admitted to Ortho • Next morning, Na corrected to 136 • Later that evening, pt develops confusion, dysarthria, unable to move her arms and legs • What’s happening? Call stroke team?

  19. Central Pontine Myelinolysis (CPM) • Overaggressive correction of the serum sodium level (usually >12 mEq/L/day) • Destruction of myelin in the pons (due to rapid changes in cell volume?) • Pts may develop confusion, cranial nerve palsies, spastic quadriplegia, or coma • More likely to occur in patients with chronic hyponatremia • Most cases reported in alcoholic, malnourished, and elderly patients • Can develop 1-3 days after rapid Na correction • Diagnosed by MRI • Supportive Management

  20. Treatment (mild-mod symptoms) • Hypovolemic hyponatremia • Correct with NS (0.9%) • Euvolemic hyponatremia: • Restrict free water intake • Treat underlying cause • No NS in SIADH: • Worsens due to excessive water retention • Lithium and demeclocycline • Hypervolemic hyponatremia: • Restrict free water intake • +/- diuretics (may increase Na loss)

  21. Case 3 (Jan 12, 2007 – Sacremento, CA) • 28F enters radio station competition “Hold your Wee for a Wii” • Contestant who could drink the most water without urinating won • Possibly drank up to 2 gallons • Nurse called into radio station during competition stating danger • Last heard from while driving home with severe headache • Found dead next morning

  22. Questions?

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