Approach to

Hyponatremia

Core Topic
UCI Internal Medicine Residency, 2012

Clinical Scenario

74-year-old man p/w recent gastroenteritis characterized

by n/v/d x 5 days, in addition to fatigue and headache.

CT head (-) in ED. No focal neurologic deficits found. He

looks dry on physical exam, with no evidence of fluid
overload.

BMP significant for Na+ of 118, baseline unknown. Serum

osmolality is 266. Urine osmolality is 377. Urine sodium is
8.

How would you approach this patients hyponatremia?

How would your approach be different if this patient

presented with new-onset seizures?

Lecture Objectives
Hyponatremia

Clinical manifestations

Diagnostic approach

Clinical Scenario discussed

Hyponatremia Defined
Definition: Serum Na+ <135 meq/L

Generally associated with decreased osmolality to <275

Most common electrolyte abnormality in the US

Caused by retention of water

Usually a drop in osmolality will suppress ADH to allow

excretion of the excess water via dilute urine

Most forms of hyponatremia are associated with elevated

ADH (whether appropriate or inappropriate), which
concentrates urine

Signs & Symptoms

More profound when the decrease in sodium is very large

or occurs rapidly (i.e. over hours)

Generally asymptomatic if Na+ level >125

Symptoms include:

Headache
Nausea, vomiting
Muscle cramps
Disorientation, depressed reflexes, lethargy, restlessness
Seizure, coma, permanent brain damage, respiratory arrest,
brainstem herniation & death
Serious complications are more commonly seen in primary
polydipsia, after surgery, and in menstruating women

Approach to Hyponatremia
1st assess volume status

Is the patient volume overloaded, depleted, or euvolemic?

2nd assess osmolality (hyper, iso, or hypo)

Is the blood concentrated? For hypotonic hyponatremia,

continue to 3rd step:

3rd assess urinary sodium excretion and FeNa %

Is the urine concentrated?

*Remember VOU volume status, osmolality, and urine studies

STEP 1 (V) Volume Status

1st assess volume status (extracellular fluid volume)
Hypotonic hyponatremia has 3 main etiologies:

Hypovolemic both H2O and Na decreased (H20 < Na)

Consider obvious losses from diarrhea, vomiting,
dehydration, malnutrition, etc

Euvolemic H20 increased and Na stable

Consider siADH, thyroid disease, primary polydipsia

Hypervolemic H20 increased and Na increased (H2O >

Na)
Consider obvious CHF, cirrhosis, renal failure

STEP 2 - (O) Osmolality

2nd assess osmolality hyper, iso, or hypo

Hypotonic hyponatremia = warrants further workup, especially when

there is no obvious fluid overload or depletion

Serum Osmolality: lab value or calculation in mosm/kg

=(2 x Na+) + (glucose/18) + (BUN/2.8) + (ethanol)/4.6

Hypertonic - >295
hyperglycemia, mannitol, glycerol
Isotonic - 280-295
pseudo-hyponatremia from elevated lipids or protein
Hypotonic - <280
excess fluid intake, low solute intake, renal disease, siADH,
hypothyroidism, adrenal insufficiency, CHF, cirrhosis, etc.

STEP 3 (U) Urine Studies

For euvolemic hyponatremia, check urine osmolality

Urine osmolality <100 - excess water intake

Primary polydipsia, tap water enemas, post-TURP

Urine osmolality >100 - impaired renal concentration

siADH, hypothyroidism, cortisol deficiency

Check urine sodium & calculate FeNa %

A low urine sodium (<10) and low FeNa (<1%) implies the
kidneys are appropriately reabsorbing sodium

A high urine sodium (>20) and high FeNa (>1%) implies

the kidneys are not functioning properly

Hyponatremia Flow Sheet

Treatment of Hyponatremia

Be CAUTIOUS with correction:

0.5 meq/L increase per every hour initially

Do not increase Na more than 10 meq/L in 24 hrs or 18

meq/L in 48 hrs

Treatment varies greatly by etiology of hyponatremia,

and it is important to look-up via online or other
resources.

Clinical Scenario - Conclusion

74-year-old man p/w recent gastroenteritis characterized by n/v/d x 5 days, in

addition to fatigue and headache.

BMP significant for Na+ of 118, baseline unknown. Serum osmolality is 266. Urine
osmolality is 377.

How would you approach this patients hyponatremia? The steps:

1) Serum osmolality 266, decreased (hypotonic)

2) Urine osmolality 377, increased (>100)

3) Volume status - hypovolemic

4) Urine Na, FeNa urine Na 8, appropriately reabsorbing, likely volume depleted 2/2 N/V

5) Treatment: Mild symptoms, correct slowly w/ isotonic saline

How would your approach be different if this patient presented with new-onset
seizures?

For symptomatic, severe hyponatremia, more rapid correction using 3% normal saline

TAKE HOME POINTS

Symptoms: Usually Na <125 or rapid decline

WORK-UP in 3 important steps (V-O-U):

N/V, headache, lethargy, AMS, seizures, coma

1) Assess volume status

2) Assess serum osmolality
3) Check urine sodium, osmolarity, & calculate FeNa

Treatment varies by etiology, but cautious correction of

sodium important to prevent demyelination as fluid leaves
the brain