Sodium Disorders in the Emergency Department: A Review of Hypernatremia and Hyponatremia

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Publication Date: April 2024 (Volume 27, Number 4)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 04/01/2028.

Authors

Peer Reviewers

Abstract

Manifestation of sodium disorders will depend on the rapidity of development, the absolute level of sodium, and the patient’s overall health. Acute symptomatic hypernatremia should be corrected rapidly, while chronic hypernatremia is generally corrected more slowly due to the risks for brain edema during treatment. Hyponatremia symptoms are vague, but acute severe symptomatic hyponatremia, whether self-induced, drug-related, or hospital-acquired, is a medical emergency that demands immediate recognition and intervention. This issue reviews the evidence on the causes, diagnosis, and treatment of hypernatremia and hyponatremia in the emergency department, focusing on early recognition and best-practice management.

Case Presentations

A 93-year-old man with a history of dementia, diabetes, and hypertension arrives from a skilled nursing facility for confusion and weakness…

• The patient has had diarrhea and vomiting for the previous 4 days. Current medications include metformin, hydrochlorothiazide, lisinopril, and aspirin.
• His vital signs on arrival in the ED are: oral temperature, 38.7°C; heart rate, 114 beats/min; blood pressure, 86/53 mm Hg; respiratory rate, 24 breaths/min; and oxygen saturation, 94% on 3 L nasal cannula.
• On physical examination, he is cachectic, with dry oral mucous membranes, and is reportedly more confused than his baseline. His abdomen is soft and nontender, with no rebound or guarding. However, he does have an episode of nonbloody, nonbilious emesis during your examination.
• Blood is obtained, and a serum chemistry panel shows: sodium, 154 mEq/L; potassium, 3.9 mEq/L; chloride, 108 mEq/L; bicarbonate, 14 mEq/L; BUN, 55 mg/dL; creatinine, 2.0 mg/dL; and glucose, 112 mg/dL. The nurse asks you what IV fluids you want and how fast...

A 19-year-old college student presents by ground ambulance with new-onset seizure activity that persists despite the 5 mg of lorazepam administered en route…

• Her roommate said she called the ambulance because her friend was vomiting and confused this morning after a long night of drinking alcohol and taking ecstasy. EMS noted multiple empty beer cans and empty shot glasses scattered around the dorm room, but no empty pill bottles were seen.
• On arrival at the ED, the team administered 2 mg IV lorazepam for continued tonic-clonic seizure activity. Her vital signs are: oral temperature, 37.7°C; heart rate, 129 beats/min; blood pressure, 146/64 mm Hg; respiratory rate, 13 breaths/min; and oxygen saturation, 93% on 100% oxygen via nonrebreather mask. Her finger-stick glucose result is 89 mg/dL.
• The patient’s seizures persist, despite a total of 10 mg of lorazepam and a loading dose of levetiracetam administered. The patient is intubated, and shortly thereafter her blood chemistries return, revealing: sodium, 104 mEq/L; potassium, 3.0 mEq/L; chloride, 112 mEq/L; bicarbonate, 16 mEq/L; BUN, 51 mg/dL; creatinine, 1.5 mg/dL; and glucose, 89 mg/dL.
• You realize that the patient’s hyponatremia needs to be emergently corrected, but you wonder: how fast is too fast...

A 43-year-old man collapses at mile 24 of his first full marathon (26.2 miles) and is rushed to the emergency medical tent staffed by EMS providers and emergency clinicians, including yourself…

• The patient is protecting his airway and has a bounding radial pulse, but he is confused, has edema of the fingers and wrists, and is vomiting. He has normal skin turgor and color. His running partner states that he had his friend stop at every water stop during the race to make sure he remained hydrated.
• The medic establishes IV access. The patient‘s vital signs include: temperature, 39.0°C; pulse, 138 beats/min; blood pressure, 99/53 mm Hg; and oxygen saturation, 100% via a nonrebreather mask.
• The paramedic you are working with suspects dehydration and tells you that he plans to aggressively rehydrate the athlete with 2 L of normal saline. You have a different plan…

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