Disorders of Sodium and Water Balance

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Key points

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    Correct hypovolemia before correcting sodium imbalance by giving patients boluses of isotonic intravenous fluids; reassess serum sodium after volume status normalized.

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    Serum and urine electrolytes and osmolalities in patients with dysnatremias in conjunction with clinical volume assessment are especially helpful to guide management.

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    If an unstable patient is hyponatremic, give 2 mL/kg of 3% normal saline (NS) up to 100 mL over 10 minutes; this may be repeated once if the patient continues to be

Physiology

Total body water (TBW) accounts for approximately 60% of the total body weight in adults (Fig. 1); however, this figure changes with extremes of age, and within the sexes.2 A more accurate picture of TBW can be calculated by (Equation 1, Table 1):TBW=weight(kg)×correctionfactor

The TBW is further divided into intracellular fluid, approximately 40% of total body weight; and extracellular fluid (ECF), approximately 20% of total body weight. Of the ECF, approximately two-thirds comprises

Hyponatremia

Hyponatremia, defined as serum sodium level of less than 135 mEq/L, or severe hyponatremia as a level less than 125 mEq/L, is most commonly encountered in hospitalized patients or in patients with underlying medical diseases. The prevalence of hyponatremia is estimated to range between 3 and 6 million persons per year in the United States, and approximately one-quarter of these patients likely seek initial medical treatment in the emergency department.8 Approximately 4% of adult medicine

Hypernatremia

Hypernatremia is defined as serum sodium level greater than 145 mEq/L and is less common than hyponatremia. Most commonly, hypernatremia occurs in hospitalized patients, but it can also occur in approximately 0.2% of patients who present to the emergency department.97

Hypernatremia is always associated with intracellular dehydration caused by decrease of TBW and is always associated with decreased intake of free water. As a result of losses through bowel, urine, and pulmonary losses, without

Fluids used for resuscitation

In most cases of sodium imbalance, intravascular volume is depleted. The first priority of management in a patient with dysnatremia when associated with hypovolemia is restoration of the intravascular space. Infusion of isotonic 0.9% NS is the best initial fluid choice. In patients with preserved renal function, the patient excretes either excess sodium or water through the urine.2, 7 Even if the patient does not have normal renal function, intravascular volume takes priority over sodium

Summary

Disorders of sodium and water occur simultaneously. The emergency physician must be aware of these disorders to quickly and accurately identify them in life-threatening situations. Often, disorders of sodium and water are chronic, but acute cases require rapid intervention. Before evaluation or possible correction of a sodium imbalance, the clinician must correct any intravascular volume losses. This correction is best achieved by infusion of isotonic NS. If depleted intravascular volume is the

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