Hyponatremia
Hyponatremia
A Word Of Caution: Hyponatremia is a tricky one. Its easy to do harm when trying to normalize a lab value. Please do not put vague hyponatremia in CDU, these should be admitted. Chronic Hyponatremia (such as in many Cirrhotic patients) also should not be corrected, and if asymptomatic should probably be discharged. It is very reasonable to get a hospital medicine consult if you are unsure.
Patient with an established and reasonably certain cause of hyponatremia
Recent Hydrochlorothiazide
Volume Depletion from Vomiting/Diarrhea
Polydipsia / Beer Potomania
Serum Osmolality, TSH, Urinalysis, Urine Osmolality, Urine Electrolytes done in Main ED
Serum Na less than 135 but greater than 125
Serum Osmolality < 285 (If it is normal or high, it is not true hyponatremia)
Normal Mental Status
Serum Na+ < 125
Serum Osmolality <
Suspected SIADH
Emergency Department provider has high clinical suspicion of central vertigo or stroke
Any new neurologic symptom, including headache, confusion, AMS etc.
Patients requiring placement in a rehab facility, nursing home, or other long-term facilities.
Want to get nerdy on hyponatremia? I really like this podcast episode and the accompaning show notes: Curbsiders Reboot Hyponatremia
BMP Q8hr
Strict I&O measurements
Therapy Depends on the Etiology
Volume Depletion (Gastroenteritis etc)
IV NS 0.9% bolus and then Maintenance Fluids
Tea and Toast / Beer Potomania
Gentle IVF with 0.9% NS
A good meal
Polydipsia
1000 ml fluid restriction
Recent Hydrochlorothiazide
Stop HCTZ
1500 ml fluid restriction
Disposition
Serum Na+ > 135
Minimal if any symptoms
At baseline functional status
Plan to prevent relapse of hyponatremia (have some salted nuts with your beer dude)
Normal Vital signs
Worsening Lab Values
Any change in mental status or neurologic symptom
Cause of Hyponatremia not clear
Patient unable to ambulate
Learning Links: