Hyponatremia in Emergency Medicine Clinical Presentation

The number and severity of symptoms increase with the degree of hyponatremia and the rapidity with which it develops. When the serum sodium level falls gradually, over a period of several days or weeks, sodium levels as low as 110 mEq/L may be reached with minimal symptomatology. In contrast, an equivalent fall in serum sodium level over 24-48 hours may overwhelm compensatory mechanisms, leading to severe cerebral edema, coma, or brainstem herniation.

Symptoms range from mild anorexia, headache, and muscle cramps, to significant alteration in mental status including confusion, obtundation, coma, or status epilepticus.

Hyponatremia is often seen in association with pulmonary/mediastinal disease or CNS disorders. Hyponatremia must be considered in patients with pneumonia, active tuberculosis, pulmonary abscess, neoplasm, or asthma, as well as in patients with CNS infection, trauma, or neoplasm. Patients with carcinoma of the nasopharynx, duodenum, stomach, pancreas, ureter, prostate, or uterus also have an increased risk.

Hyponatremia is associated with numerous medications. The patient's medication list should be examined for drugs known to cause hyponatremia.

Hyponatremia has been noted in patients with poor dietary intake who consume large amounts of beer (known as beer potomania) and after use of the recreational drug N- methyl-3,4-methylenedioxyamphetamine (ie, MDMA or ecstasy). MDMA-induced hyponatremia occurs via multiple mechanisms; these include the induction of syndrome of inappropriate antidiuretic hormone secretion (SIADH), the encouragement to drink large amounts of water to prevent unpleasant side effects of the drug, and the tendency among those intoxicated to be involved in vigorous physical activity that results in heavy sweating.

A history of hypothyroidism or adrenal insufficiency should be sought because each is associated with hyposmolar hyponatremia.

Patients with clinically significant hyponatremia present with nonspecific symptoms attributable to cerebral edema. These symptoms, especially when coupled with a recent history of altered fluid balance, should suggest the possibility of hyponatremia.

• Anorexia

• Nausea and vomiting

• Difficulty concentrating

• Confusion

• Lethargy

• Agitation

• Headache

• Seizures

Physical findings are highly variable and dependent on the degree and the chronicity of hyponatremia. Patients with acutely developing hyponatremia are typically symptomatic at a level of approximately 120 mEq/L. Those patients with chronic hyponatremia tolerate much lower levels.

Most abnormal findings on physical examination are neurologic in origin.

• Level of alertness ranging from alert to comatose

• Variable degrees of cognitive impairment (eg, difficulty with short-term recall; loss of orientation to person, place, or time; frank confusion or depression)

• Focal or generalized seizure activity

• In those patients with acute severe hyponatremia, signs of brainstem herniation, including coma; fixed, unilateral, dilated pupil; decorticate or decerebrate posturing; sudden severe hypertension and respiratory arrest

In addition to neurologic findings, patients may exhibit signs of hypovolemia or hypervolemia. Determining the hydration status of the patient may help establish the etiology of the hyponatremia and direct subsequent treatment.

• Dry mucous membranes, tachycardia, diminished skin turgor, and orthostasis suggest hypovolemic hyponatremia due to excessive loss of body fluids and replacement with inappropriately dilute fluids.

• Pulmonary rales, S₃ gallop, jugular venous distention, peripheral edema, or ascites suggest hypervolemic hyponatremia due to excess retention of sodium and free water (ie, cirrhosis, nephrotic syndrome, congestive heart failure).

• Patients who lack findings of hypovolemia or hypervolemia are considered to have euvolemic hyponatremia, which is consistent with such etiologies as exogenous free water load, hypothyroidism, cortisol deficiency, or SIADH.

Other nonspecific signs include muscle weakness and cramping. Rhabdomyolysis is an occasional consequence of hyponatremia and should be considered in patients with muscle pain or tenderness.

Hypovolemic hyponatremia develops as sodium and free water are lost and replaced by inappropriately hypotonic fluids, such as tap water, half-normal saline, or dextrose in water. Sodium can be lost through renal or nonrenal routes. Nonrenal routes include GI losses, excessive sweating, third spacing of fluids (eg, ascites, peritonitis, pancreatitis, burns), and cerebral salt-wasting syndrome.

• Excess fluid losses (eg, vomiting, diarrhea, excessive sweating, GI fistulas or drainage tubes, pancreatitis, burns) that have been replaced primarily by hypotonic fluids
• Salt-wasting nephropathy

Cerebral salt-wasting syndrome seen in patients with traumatic brain injury, aneurysmal subarachnoid hemorrhage, and intracranial surgery. Cerebral salt-wasting must be distinguished from SIADH because both conditions can cause hyponatremia in neurosurgical patients, and yet the pathophysiology and treatment are different. ^[12]

Prolonged exercise in a hot environment, especially in patients who hydrate aggressively with hyposmolar fluids during exertion, is another cause of hyponatremia. Severe symptomatic hyponatremia has been reported in marathon runners and in recreational hikers in the Grand Canyon.

A study by Giordano et al found a significant increase in the prevalence of hyponatremia in elderly patients visiting a university hospital emergency department during the summer. Prevalence during the summer was 12.5% (zenith) in the elderly, compared with a mean monthly prevalence of 10.3% in these patients. The investigators suggested that factors such as reduced renal function, salt loss, a decline in salt intake, and increased water ingestion may play a role in the increased prevalence of hyponatremia in the elderly during hot-weather months. ^[13]

Similarly, a study by Huwyler et al found an increased incidence of adult patients with profound hyponatremia in a university hospital emergency department during the summer (1.29%, compared with 0.54% in the winter). Based on multivariate analysis, the investigators reported that the rise in incidence was related to patient age, the presence of psychiatric disorders, and the use of diuretics (either potassium-sparing or thiazide). ^[14]

Euvolemic hyponatremia implies normal sodium stores and a total body excess of free water. This occurs in patients who take in excess hypotonic fluids.

• Psychogenic polydipsia, often in psychiatric patients

• Administration of hypotonic intravenous or irrigation fluids during procedures or in the immediate postoperative period ^{[15, 16]}

• In one meta-analysis, administration of hypotonic maintenance intravenous fluids to hospitalized children has been associated with an increased incidence of acute hyponatremia compared with administration of isotonic maintenance fluids. ^[17]

• Infants who may have been given inappropriate amounts of free water

• Ingestion of sodium phosphate or sodium picosulfates and magnesium citrate combination as a bowel preparation before colonoscopy or colorectal surgery ^[18]

• SIADH

Hypervolemic hyponatremia occurs when sodium stores increase inappropriately. This may result from renal causes such as acute or chronic renal failure, when dysfunctional kidneys are unable to excrete the ingested sodium load. It also may occur in response to states of decreased effective intravascular volume. History of hepatic cirrhosis, congestive heart failure, or nephrotic syndrome, in which patients are subject to insidious increases in total body sodium and free water stores

• Uncorrected hypothyroidism or cortisol deficiency (adrenal insufficiency, hypopituitarism)

• Consumption of large quantities of beer or use of the recreational drug MDMA (ecstasy)

Hyponatremia can be caused by many medications. Known offenders include acetazolamide, amiloride, amphotericin, aripiprazole, atovaquone, thiazide diuretics, amiodarone, basiliximab, angiotensin II receptor blockers, angiotensin-converting enzyme inhibitors, bromocriptine, carbamazepine, carboplatin, carvedilol, celecoxib, cyclophosphamide, clofibrate, desmopressin, donepezil, duloxetine, eplerenone, gabapentin, haloperidol, heparin, hydroxyurea, indapamide, indomethacin, ketorolac, levetiracetam, loop diuretics, lorcainide, mirtazapine, mitoxantrone, nimodipine, oxcarbazepine, opiates, oxytocin, pimozide, propafenone, proton pump inhibitors, quetiapine, sirolimus, ticlopidine, tolterodine, vincristine, selective serotonin reuptake inhibitors, sulfonylureas, trazodone, tolbutamide, venlafaxine, zalcitabine, and zonisamide. ^[19]

In the aforementioned Swiss-Austrian study, major risk factors for hyponatremia in emergency patients with AKI included the use of potassium-sparing or thiazide diuretics, a medical cause for emergency referral, and AKI stage. ^[4]

A study by Poddighe of 328 pediatric emergency department patients indicated that a systemic inflammatory condition is associated with mild hyponatremia during acute illnesses, finding, in the 98 patients determined to have (mostly mild) hyponatremia, a link between lower plasma sodium levels and higher levels of C-reactive protein. ^[20]

Overall, the above causes are not mutually exclusive, with hyponatremia often resulting from multiple factors. ^[21]

Complications related to hyponatremia include rhabdomyolysis, seizures, permanent neurologic sequelae related to ongoing seizures or cerebral edema, respiratory arrest, and death.

A retrospective study by Brouns et al indicated that among elderly internal medicine patients presenting to the emergency department, hyponatremia is a risk factor for hospital admission, longer hospital stay, and 3-month mortality, with moderate hyponatremia being particularly associated with frailty and mortality. In a comparison of hyponatremic elderly patients with those who did not have clinically relevant hyponatremia, admission rates were 93.4% versus 72.9%, respectively; hospital stay was 8 days versus 6 days, respectively; and 3-month survival rate was 74% versus 83%, respectively. ^[22]

Complications related to therapy of hyponatremia include fluid overload and the osmotic demyelination syndrome.