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Hypernatremia
1. Elderly Lady with Altered Sensorium
DR.SUNIL KUMAR
Master in EmergencyMedicine
Dr.Mehta’s HospitalPvt. Ltd.
2. Case presentation
A 74 Year old Lady presented to ED
H/o Drowsiness and Reduced urine output
since one day.
H/o poor food intake since one day.
H/o Altered level of consiousness since one
day.
13. Patho-physiology
Hypernatremia results
from a deficit in TBW
and/or a net gain of
Na+ .
When [Na+] and osmolality
increase, normal subjects
become thirsty, drink free water,
and the Na+ level returns
toward nor- mal.
14.
15.
16.
17. All the above patients are at particular risk of
developing hypernatremia.
Elderly patients infants Hospitalized pt
Dcompensated DM
Pt
massive salt overdose
18. to continue…….
Any clinical situation that impairs the
patient’s sense of thirst, limits the
availability of water, limits the kidney’s
ability to concentrate urine, or results
in increased salt intake predisposes
the patient to hypernatre- mia.
20. Hypovolemic hypernatremia
Extra Renal –UNa < 10 Renal- UNa > 20
Sweating
Diarrhea
Burns
Heat exposure
Osmatic diauresis
Manitol
Uncontrolled DM
Rx NS
Na
Lost – Salt – Na + H2O
F
ICF ECF
Loss
21. Hypervolemic Hypernatremia
Retention-salt – Na + Water
Over - IVF Hypertonic NaCl , NaHCO3.
Cushing disease- To much ACTH- Mineralocorticoid access
Aldosterone – Na Reabsortion
22. Isovolemic Hypernatremia
loss of free water (H2o) And Low ADH
EEEEEEEEEEEEEE ECF
ICF
Diabetes insipidus - in this disease where the ability of the
kidney to reabsorb free water is compromised this is
charecterized by polyuria polydipsia and increased vol of
hypo-osmolar urine ,It can be neurogenic inadequate ADH
Secretion or nephrogenic do not resopnding to ADH.
23. Causes-”High salt”
H – Hypercortisolism
I - Incresed Na intake ( oral or ivf )
G - GI ( Diarrhea)
H - Hypertonic solution ( 3% Nacl)
S - Sodium retantion( corticosteroids)
A – ADH (DI).
L - Loss of fluid ( dehydration ,sweating)
24. Clinical Features
Type
Osmolality (
mOsm/kg)
350-375
Clinical features
Mild
( Na-146-149) 350-375
Restlessness irritability
, nausea vomiting
Increased thirst
Moderate
(Na-150-169)
375-400
Tremor , ataxia,
weakness,
polyuria
Severe
(Na->170)
400-430
>430
Hyperreflexia,Twitching
,altered mental status
Spasticity.
Seizures and death
26. Diagnosis
Focus on the Presence /absence of thirst, polyuria and
source of water loss,
Physical and neurological examination
Daily fluid intake and daily urine output is critical for the
diagnosis and management of hypernatremia
Serum electrolytes and osmolality , urine osmolality,
urea/ creatinine ratio
27. Formula for Water deficit
Free water deficit = TBW X Posm-285/Posm
Free water deficit : TBW x (SerumNa / 140-1)
TBW= 50% OF Body wt in women &
60% in men
Posm =2 x( Na+)+ glu / 18
30. Choice of fluid
At home – Drink water
At hospital- iv saline
NS (0.9%) – Use for correction of volume
deficits
D5W –in case of chronic
hypernatremia/pure water loss ( DI)
0.45% normal saline-mild to moderate
hypernatremia
Haemodialysis- life threatening acute
case of salt ingestion
32. Osmotic Demyelination Syndrome
Demyelinating lesion in the brain that occurs with overly rapid correction of
hyponatremia( >12 mEq/L/24 h) .
it is mainly two types
. Central pontine myelinolysis
. Extrapontine myelinolysis
Risk factors for osmotic demyelination syndrome include [Na+] <120 mEq/L,
chronic heart failure, alcoholism, cirrhosis, hypokalemia, malnutrition, and
treatment with vasopressin antagonists such as tolvap- tan.
36. KEY POINTS
In a patients who failed to recover as
expected after a severe illness & manifesties
& clinical symptoms as describe previously
and if imaging is negative
