Dr. Melanie Baimel and Dr. Ed Etchells discuss the emergency management of hyponatremia, including assessing and treating neurologic emergencies, defending intravascular volume, preventing exacerbation, and ascertaining the cause. They answer questions about giving DDAVP, determining the cause, correcting hyponatremia, fluid resuscitation, managing marathon runners, and minimizing the risk of Osmotic Demyelination Syndrome (ODS) and cerebral edema.
Assess and treat neurologic emergencies related to hyponatremia with hypertonic saline.
Defend the intravascular volume.
Prevent rapid overcorrection.
Deep dives
Maintaining Adequate Intravascular Volume and Preventing Worsening Hyponatremia
In managing hyponatremia, it is important to assess the patient's volume status and provide appropriate fluid resuscitation if they are hypovolemic. In the case of hypervolemia or euvolemia, fluid restriction is recommended to prevent worsening hyponatremia. The use of normal saline or ringers lactate is preferred over hypotonic fluids to avoid rapid overcorrection of sodium levels. Monitoring postural vital signs can help determine the need for fluid boluses.
Preventing Rapid Overcorrection and Osmotic Demyelination Syndrome
To prevent rapid overcorrection of hyponatremia, urine output should be monitored. If urine output exceeds 100 cc per hour, a stat urine osmolality should be sent. If the osmolality is less than 100, administration of DDAVP is recommended to prevent further correction. It is crucial to make the patient NPO and restrict hypotonic fluids to avoid exacerbating the condition. Rapid overcorrection can lead to osmotic demyelination syndrome, resulting in severe neurological symptoms.
Managing Hyponatremia and Avoiding Complications
When managing hyponatremia, it is essential to follow a systematic approach. This includes assessing volume status, preventing worsening hyponatremia through fluid restriction, monitoring urine output to prevent rapid overcorrection, and determining the underlying cause of the hyponatremia. It is advisable to consult a nephrologist for cases requiring more specialized intervention. Additionally, awareness of potential complications, such as osmotic demyelination syndrome, can help guide management decisions and ensure patient safety.
Causes of HYponatremia and their presentation
The podcast discusses several causes of hyponatremia, such as nausea, vomiting, diarrhea, reduced PO intake, pain, medications (including thiazide diuretics), past medical history (heart failure, renal failure, liver failure), certain types of cancer, and lab results. It emphasizes the importance of considering hypothyroidism and adrenal insufficiency as potential diagnoses when evaluating patients with hyponatremia.
Management of Hyponatremia
The podcast highlights the importance of defending intravascular volume, preventing worsening hyponatremia, avoiding rapid over-correction, and identifying the underlying cause. It suggests specific management strategies depending on the patient's volume status, such as fluid restriction and giving furosemide for hypervolemic patients, and considering 3% hypertonic saline for neurologic emergencies. It also provides guidance on correcting hyponatremia based on the severity of symptoms and warns against common pitfalls in treatment, such as over-hydration in marathon runners and unnecessary fluid administration in certain cases.
In this EM Cases episode Dr. Melanie Baimel and Dr. Ed Etchells discuss a simple and practical step-wise approach to the emergency management of hyponatremia:
1. Assess and treat neurologic emergencies related to hyponatremia with hypertonic saline
2. Defend the intravascular volume
3. Prevent further exacerbation of hyponatremia
4. Prevent rapid overcorrection
5. Ascertain a cause
Dr. Etchells and Dr. Baimel answer questions such as: What are the indications for giving DDAVP in the emergency management of hyponatremia? What is a simple and practical approach to determining the cause of hyponatremia in the ED? How fast should we aim to correct hyponatremia? What is the best fluid for resuscitating the patient in shock who has a low serum sodium? Why is the management of the marathon runner with hyponatremia counter-intuitive? What strategies can we employ to minimize the risk of Osmotic Demyelination Syndrome (OSD) and cerebral edema in the emergency management of hyponatremia? and many more...
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