case 1- m.h. (chico state u., california)
DESCRIPTION
Case 1- M.H. (Chico State U., California). 18M presents after 3 grand-mal seizures after collapsing during fraternity hazing ritual Pledges were forced to do push-ups/exercises for hours in raw sewage that had leaked into basement of fraternity - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/1.jpg)
![Page 2: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/2.jpg)
Case 1- M.H. (Chico State U., California)
18M presents after 3 grand-mal seizures after collapsing during fraternity hazing ritual
Pledges were forced to do push-ups/exercises for hours in raw sewage that had leaked into basement of fraternity
Kept drinking from 5 gallon jug of water which was continuously refilled
Vomitted and urinated on themselves
![Page 3: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/3.jpg)
Case 1
Initial vitals: 120/60 70 20 98% RA T=37.5 Clinically euvolemic Confused
![Page 4: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/4.jpg)
Case 1
Initial labs Na = 110, urine Na <10, serum osmol = 270 How would you treat?
![Page 5: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/5.jpg)
Hyponatremia
Sultana Qureshi, R2Lab RoundsFeb 8, 2007
Matthew Harrington
![Page 6: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/6.jpg)
HypoNa Basics
HypoNa is a symptom of disease Na <135 mEq/L Most common lyte abn in hospital
pts Incidence 1%, increases with age Acute, symptomatic cases,
mortality up to 18%
![Page 7: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/7.jpg)
Quick Physiology Review 3 fluid compartments
(2/3) ICF & (1/3)ECF (InterstitialF + IVF) Na concentration governs movement of
water across these spaces
Body tightly maintains serum osmolality within 1-2% of 275-295 mosmol/kg
Na balance = Renin-angiotensin Water balance = ADH
![Page 8: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/8.jpg)
Quick Physiology Review
Hypotension or low ECF renin release from JGAangiotensin II aldosterone production Na reabsorption and K excretion
Incr serum osmolality, Decr. BP or volume ADH release from post. Pituitary More sens to hypovolemia than low
osmol.
![Page 9: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/9.jpg)
Clinical Features
Absolute Na level not as important as RATE OF DECLINE
![Page 10: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/10.jpg)
SymptomsSerum Na+ (mEq/L) Symptoms
135 - 130 Decreased taste
130 - 125 ThirstAnorexia, N + VMuscle cramps
125 - 120 WeaknessLethargy
RestlessnessConfusion
< 120 DeliriumComa
SeizuresThanks to Moritz!
![Page 11: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/11.jpg)
Approach
Classify Osmolality and Volume status Osmolality
Hyperosmolar – excess solutes (ie glucose) draw water into ECF diluting Na
Iso-osmolar – psuedohyponatremia Hypo-osmolar (MOST COMMON) – excess
water in relation to Na stores (may be incr, decr or n) – categorized by volume status
![Page 12: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/12.jpg)
Hypo-osmolar HypoNa Hypervolemic
CHF, ARF, CRF, cirrhosis/ascites, pregnancy Euvolemic
SIADH, adrenal insuff, hypothyroid, psychogenic polydipsia, sports
Hypovolemic Diuretics, diarrhea, sweating, third-spacing,
salt-wasting nephropathy
![Page 13: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/13.jpg)
Causes of SIADH CNS disease
Brain tumor infarction injury abscess Meningitis/ Encephaliti
s
Pulmonary disease Pneumonia Tuberculosis Lung abscess Pulmonary
aspergillosis
Drugs
Exogenous vasopressin (enuresis)
Diuretics Chlorpropamide Vincristine Thioridazine Cyclophosphamide
![Page 14: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/14.jpg)
![Page 15: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/15.jpg)
Most common is hypo-osmolar hyponatremia
![Page 16: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/16.jpg)
Case 2
75F – weak and dizzy x 1 week, falls at home presenting with hip #
PMHx – Hyperlipidemia, HTN, chronic diarrhea NYD
Meds: HCTZ, lipitor Vitals: 85, 110/70, 14, 95% RA
![Page 17: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/17.jpg)
Case 2
Labs: Na- 112, K-4.5, Cl- 82, CO2 -12
Serum osmol – 240 Urine osmol – 300 Urine Na - <10 Cause of HypoNa? How would you treat?
![Page 18: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/18.jpg)
![Page 19: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/19.jpg)
Management
Guided by severity of symptoms and acuity
Chronic Gradual correction <0.5 mEq/L/hr
Acute/Symptomatic Tolerate faster correction up to 1-2
mEq/l/hr
![Page 20: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/20.jpg)
![Page 21: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/21.jpg)
Management CNS symptoms/seizures
Correct with hypertonic saline (3%) until resolved
usually need to increase Na by 4-6 mEq/L only Then correct 8-10mEq/L/day Formula
(Desired [Na+] – measured [Na+] ) x 0.6Wt(kg) = mEq Na+ req’d
Eg (117-112) X 0.6(70) = 210 mEq
![Page 22: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/22.jpg)
![Page 23: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/23.jpg)
Case 2 (continued) It’s July 1st and the Ortho R1 decides to
fluid resuscitate her with NS 2L bolus, then runs it at 200cc/hr
Pt admitted to Ortho Next morning, Na corrected to 136 Later that evening, pt develops
confusion, dysarthria, unable to move her arms and legs
What’s happening? Call stroke team?
![Page 24: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/24.jpg)
Central Pontine Myelinolysis (CPM) Overaggressive correction of the serum sodium level
(usually >12 mEq/L/day)
Destruction of myelin in the pons (due to rapid changes in cell volume?)
Pts may develop confusion, cranial nerve palsies, spastic quadriplegia, or coma
More likely to occur in patients with chronic hyponatremia
Most cases reported in alcoholic, malnourished, and elderly patients
Can develop 1-3 days after rapid Na correction
Diagnosed by MRI
Supportive Management
![Page 25: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/25.jpg)
![Page 26: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/26.jpg)
![Page 27: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/27.jpg)
Treatment (mild-mod symptoms) Hypovolemic hyponatremia
Correct with NS (0.9%) Euvolemic hyponatremia:
Restrict free water intake Treat underlying cause No NS in SIADH:
Worsens due to excessive water retention Lithium and demeclocycline
Hypervolemic hyponatremia: Restrict free water intake +/- diuretics (may increase Na loss)
![Page 28: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/28.jpg)
Case 3 (Jan 12, 2007 – Sacremento, CA)
28F enters radio station competition “Hold your Wee for a Wii” Contestant who could drink the most water
without urinating won Possibly drank up to 2 gallons Nurse called into radio station during
competition stating danger Last heard from while driving home with
severe headache Found dead next morning
![Page 29: Case 1- M.H. (Chico State U., California)](https://reader035.vdocuments.site/reader035/viewer/2022070412/56814bb9550346895db889dd/html5/thumbnails/29.jpg)
Questions?