First 5 minutes critical patient workflow
›Immediate stabilization
›Airway protection for coma or recurrent seizure
›Oxygen for hypoxia
›Cardiac monitor
›Two large bore IV lines if unstable
›Point of care glucose
›Time critical targets
›Sodium result as soon as available
›CT head if seizure or focal deficit without delay
›Immediate consult triggers
›ICU for severe symptoms or 3% sodium chloride requirement
›Nephrology for severe hyponatremia or complex correction
›Endocrinology for suspected adrenal crisis or unclear endocrine driver
Hypertonic saline for symptomatic hypotonic hyponatremia
›Indications for 3% sodium chloride
›Seizure
›Coma
›Severe confusion
›Signs of elevated intracranial pressure
›Bolus strategy options guideline dependent
›3% sodium chloride 100 mL IV over 10 minutes
›Repeat up to 2 additional boluses for persistent severe symptoms
›Alternative bolus strategy option guideline dependent
›3% sodium chloride 150 mL IV over 20 minutes
›Repeat 2 to 3 times as needed with sodium checks
›Initial correction goal
›Sodium rise 4 to 6 mmol/L
›Symptom improvement
›Monitoring during hypertonic therapy
›Sodium after each bolus
›Sodium every 2 to 4 hours during active correction
Avoiding overcorrection and relowering strategy
›Correction limits
›Target sodium rise 6 to 8 mmol/L max in 24 hours
›Target sodium rise 18 mmol/L max in 48 hours
›Desmopressin clamp strategy local protocol dependent
›Desmopressin 2 mcg IV every 8 hours
›Sodium checks every 2 to 4 hours
›Overcorrection response
›Stop hypertonic saline
›Desmopressin 2 mcg IV once or repeat per protocol
›Dextrose 5% water IV to relower sodium local protocol dependent
Etiology directed therapy after stabilization
›Hypovolemic hyponatremia
›Isotonic saline
›Stop diuretics if appropriate
›SIADH (E22.2)
›Fluid restriction
›Increase solute intake
›Loop diuretic plus oral sodium chloride local protocol dependent
›Identify and treat underlying trigger
›Hypervolemic hyponatremia
›Fluid restriction
›Loop diuretics
›Treat heart failure or cirrhosis drivers
›Adrenal insufficiency suspected in shock
›Hydrocortisone 100 mg IV now
›Hydrocortisone 50 mg IV every 6 hours
›Hypothyroidism related
›Thyroid replacement planning inpatient or outpatient
›Avoid attributing severe symptomatic hyponatremia solely to hypothyroidism
Do not do and common pitfalls
›Unsafe actions
›Hypotonic IV fluids in symptomatic hyponatremia
›Rapid correction beyond limits
›Pitfalls
›Isotonic saline can worsen SIADH
›Sudden water diuresis after volume repletion can overcorrect
›Potassium repletion can raise sodium and contribute to overcorrection
›Scheduled reassessment
›Neuro check every 1 to 2 hours until stable
›Strict intake and output
›Repeat sodium every 2 to 4 hours during active correction
›Escalation triggers
›Worsening mental status
›New seizure
›Sodium rising faster than planned