hypernatremia & hyponatremia tutorial. which of the following is not a cause of hyponatremia?...

Hypernatremia & Hyponatremia Tutorial

Which of the following is not a cause of hyponatremia?

Refer to ED lecture series and self directed workbooks

Hyponatremia

Hyperglycemia

SIADH/water intoxication

Diuretic Use

Odema/CHF/CRF

Trauma



Hyperglycaemia

Hyperglycemia


Diuretic Use

Odema/CHF/CRF

Trauma

Pseudohyponatraemia.

As glucose levels rise the osmolarity increases causing water to shift out of cells. Increased water in circulation dilutes the sodium.

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SIADH/Water Intoxication

Hyperglycemia


Diuretic Use

Odema/CHF/CRF

Trauma

Inappropriate levels of water in the system cause a dilutional effect for sodium

Next




Diuretic Use

Hyperglycemia


Diuretic Use

Odema/CHF/CRF

Trauma

The most common cause of hyponatremia is diuretic use with low salt diet in a patient with CHF

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Odema/CHF/CRF

Hyperglycemia


Diuretic Use

Odema/CHF/CRF

Trauma

The most common cause of hyponatremia is diuretic use with low salt diet in a patient with CHF

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Trauma

Hyperglycemia


Diuretic Use

Odema/CHF/CRF

TraumaNext


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

Serum Sodium


Serum Na

Urine Na & Cl

Serum glucose

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’.

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Urine Sodium & Chloride


Serum Na

Urine Na & Cl

Serum glucose

If a patient is wasting sodium it will be evident in the urine. Na below 20 = dehydrationNa 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.

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Serum Glucose


Serum Na

Urine Na & Cl

Serum glucose

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.

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Case 1

A 18yo female presents with a seizure after dancing all night. She has a sodium of 105.

Why?Dehydration

Drugs

DKA

Dehydration


Why?

Dehydration

Drugs

DKA

Dehydration is often associated with high levels of sodium as the body becomes deficient of free water.

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Drugs


Why?

Dehydration

Drugs

DKA

Think about ecstasy. Ecstasy stimulates ADH causing water retention. Also stimulates sodium secretion into the bowel.Complications are more common in females.

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DKA


Why?

Dehydration

Drugs

DKA

Measuring the plasma glucose will answer this question, also a VBG would be useful.

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Case 2

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

Hyponatremia

Hypernatremia

Hyponatremia


Hyponatremia

Hypernatremia

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.A true serum sodium will be required in this case along with a history of hydration during the event.

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Hypernatremia


Hyponatremia

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.

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Treatment

How quickly can you raise someone’s sodium?

10-12 mmol/L/day

15-20 mmol/L/day

20-25 mmol/L/day

Treatment – 10-12 mmol/L/day


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.

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10-12 mmol/L/day

15-20 mmol/L/day

20-25 mmol/L/day



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10-12 mmol/L/day

15-20 mmol/L/day

20-25 mmol/L/day

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.

Hypertonic Saline 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.

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Which of the following is not a cause of hypernatremia?


Hypernatremia

Dehydration

Diuretic Therapy

Diabetes

SIADH



Dehydration

Dehydration

Diuretic Therapy

Diabetes

SIADH

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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.




Diuretic Therapy

Dehydration

Diuretic Therapy

Diabetes

SIADH

Next

Hypernatremia secondary to diuretic therapy is common with increasing age (>65 years)




Diabetes

Dehydration

Diuretic Therapy

Diabetes

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.




Hypernatremia

Dehydration

Diuretic Therapy

Diabetes

SIADH

Next

SIADH causes a euvolemic hyponatremia. The patient will have an increased total body water with near-normal total body sodium.


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

3% hypertonic saline

Dehydration

Distalled H2O

½ Normal Saline

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?

Normal saline


Dehydration

Distilled H20

½ Normal saline


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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

½ Normal Saline



Normal saline


Dehydration

Distilled H20

½ Normal saline

Hypotension supersedes sodium values.Correct the volume deficiency first.Lowering the sodium too quickly may be fatal.


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Secure the ABC’s

Distilled H2O



Normal saline


Dehydration

Distilled H20

½ Normal saline

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.


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3% hypertonic Saline



Normal saline


Dehydration

Distilled H20

½ Normal saline


Next

Hypotension supersedes sodium values.Correct the volume deficiency first.Lowering the sodium too quickly may be fatal.

Secure the ABC’s

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

http://jasn.asnjournals.org/content/20/2/251.full

http://jasn.asnjournals.org/content/20/2/251.full

http://emedicine.medscape.com/article/766479-overview

http://emedicine.medscape.com/article/766479-overview

https://www.clinicalkey.com.au/topics/nephrology/hypernatremia.html

https://www.clinicalkey.com.au/topics/nephrology/hypernatremia.html

http://passthrough.fw-notify.net/download/489339/http:/www.slremeducation.org/wp-content/uploads/2015/02/1012.-Sodium-Disorders.pdf

hypernatremia & hyponatremia tutorial. which of the following is not a cause of hyponatremia?...

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