1. Hypernatremia & Hyponatremia Tutorial

2. 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

3. 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
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Trauma
Next
Refer to ED lecture series and self directed workbooks

4. 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
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Trauma
Next
Refer to ED lecture series and self directed workbooks

5. 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
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Trauma
Next
Refer to ED lecture series and self directed workbooks

6. 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
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Trauma
Next
Refer to ED lecture series and self directed workbooks

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

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

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

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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
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11. 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
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12. 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
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13. Case 1
A 18yo female presents with a seizure after dancing all night. She has a sodium of 105. Why?
Dehydration
Drugs
DKA

14. 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
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15. 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
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16. 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
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17. Case 2
A runner seizes at 24km and has a normal body temperature. Hyponatremia or hypernatremia?
Hyponatremia
Hypernatremia

18. 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
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19. 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
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20. Treatment How quickly can you raise someone’s sodium? 10-12 mmol/L/day

21. Treatment – 10-12 mmol/L/day
How quickly can you raise someone’s sodium?
Correct!
Never change serum Na levels by more than 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
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22. Treatment – 15-20 mmol/L/day
How quickly can you raise someone’s sodium?
Incorrect!
Never change serum Na levels by more than 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
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23. Treatment – 20-25 mmol/L/day
How quickly can you raise someone’s sodium?
Incorrect!
Never change serum Na levels by more than 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
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24. 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 mmol/L/day correction.
Next

25. 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

26. 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
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27. 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
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28. 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
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29. 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
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30. “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

31. 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

32. 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
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33. 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
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34. 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
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35. 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
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36. Treatment Same as hyponatremia Correct by no more than 0.5 mmol/hour
10-12 mmol/day

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

38. Resources
Journal of the American Society of Nephrology ( )
Medscape ( )
USCEssentials ‘KypoNa/HyperNa ’ Dr Corey Slovis
Sodium Disorders In The Emergency Department: A Review Of Hyponatremia and Hypernatremia – Emergency Medicine Practice October 2012 Volume 14, Number 10

39. Further reading