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| {{SI}} | | __NOTOC__ |
| | {{Water intoxication}} |
| | '''For patient information, click [[Water intoxication (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}} |
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| {{EH}} | | {{SK}} Hyperhydration; water poisoning |
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| ==Overview== | | == [[Water intoxication overview|Overview]] == |
| '''Water intoxication''' (also known as '''<b>hyperhydration</b>''' or '''water poisoning''') is a potentially fatal disturbance in brain function that results when the normal balance of [[electrolyte]]s in the body is pushed outside of safe limits by a very rapid intake of [[water]].<ref>{{cite web|url=http://www.hhp.ufl.edu/faculty/pbird/keepingfit/ARTICLE/toomuchwater.htm|title=You Can Drink Too Much Water|accessdate=2007-01-21|last=Bird|first=Patrick J.|year=2000|publisher=University of Florida}}</ref>
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| Normal, healthy (both physically and nutritionally) individuals have little to worry about accidentally overconsuming water. Nearly all deaths related to water intoxication in normal individuals have resulted either from water drinking contests, in which individuals attempt to consume several gallons over the course of just a few minutes, or long bouts of intensive exercise during which time electrolytes are not properly replenished, yet massive amounts of fluid are still consumed.
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| ==Physiology== | | == [[Water intoxication historical perspective|Historical Perspective]] == |
| [[Blood]] contains [[electrolyte]]s (particularly [[sodium]] compounds, such as [[sodium chloride]]) in concentrations that must be held within very narrow limits. Water enters the body orally or [[intravenously]] and leaves the body primarily in [[urine]], [[sweat]], and exhaled water [[vapor]]. If water enters the body more quickly than it can be removed, body fluids are diluted and a potentially dangerous shift in electrolyte balance occurs. In other words, the body has too much water and not enough electrolytes.
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| Most water intoxication is caused by [[hyponatremia]], an overdilution of sodium in the blood plasma, which in turn causes an [[osmosis|osmotic shift]] of water from [[extracellular fluid]] (outside of cells) to [[intracellular fluid]] (within cells). The cells swell as a result of changes in [[osmotic pressure]] and may cease to function. When this occurs in the cells of the [[central nervous system]] and [[brain]], water intoxication is the result. Additionally, many other cells in the body may undergo [[cytolysis]], wherein [[cell membrane]]s that are unable to stand abnormal osmotic pressures rupture, killing the cells. Initial symptoms typically include [[light headed|light-headedness]], sometimes accompanied by [[nausea]], [[vomiting]], [[headache]] and/or [[malaise]]. Plasma 19 sodium levels below 100 mmol/L (2.3g/L) frequently result in [[cerebral edema]], [[seizure]]s, [[coma]], and [[death]] within a few hours of drinking the excess water. As with [[alcohol poisoning]], the progression from mild to severe symptoms may occur rapidly as the water continues to enter the body from the intestines or intravenously.
| | == [[Water intoxication pathophysiology|Pathophysiology]] == |
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| A person with healthy [[kidneys]] can excrete about 900ml (0.24 gal)/hr.<ref>{{cite web|url=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11732457&dopt=Abstract|title=Peak rates of diuresis in healthy humans during oral fluid overload|accessdate=2007-01-21|last=Noakes|first=T.D.|coauthors=G. Wilson, D.A. Gray, M.I. Lambert, S.C. Dennis|year=2001|month=October|publisher=National Center for Biotechnology Information}}</ref> However, this must be modulated by potential water losses via other routes. For example, a person who is perspiring heavily may lose 1 L/hr (0.26 gal) of water through perspiration alone, thereby raising the amount of water that must be consumed before the individual crosses the threshold for water intoxication. The problem is further complicated by the amount of electrolytes lost in urine or sweat, which is variable within a range controlled by the body's regulatory mechanisms.
| | == [[Water intoxication causes|Causes]] == |
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| Water intoxication can be prevented by consuming water that is [[isotonic]] with water losses, but the exact concentration of electrolytes required is difficult to determine and fluctuates over time, and the greater the time period involved, the smaller the disparity that may suffice to produce electrolyte imbalance and water intoxication. | | == [[Water intoxication differential diagnosis|Differentiating Water Intoxication from other Diseases]] == |
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| Sodium is not the only mineral that can become overdiluted from excessive water intake. [[Magnesium]] is also excreted in urine. According to the [[National Institutes of Health]], "magnesium deficiency can cause [[metabolic]] changes that may contribute to heart attacks and strokes."<ref>''Facts about [[Dietary Supplements]],'' Office of Dietary Supplements, National Institutes of Health, March 2001.</ref> Intravenous magnesium is used in cardiac care units for [[cardiac arrhythmia]]s.<ref>Jay S. Cohen, MD, ''[[Statin]] Drugs'', 2005, page 129, ISBN 0-7570-0257-9.</ref>
| | == [[Water intoxication epidemiology and demographics|Epidemiology and Demographics]] == |
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| ==High risk factors== | | == [[Water intoxication risk factors|Risk Factors]] == |
| ===Low body mass (infants)===
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| It can be very easy for children under a year old to absorb too much water – especially if the child is under nine months old, because with their small body mass, it is easy to take in a large amount of water relative to body mass. It is also possible for a child to absorb too much water if submerged in it.<ref>[http://www.stlouischildrens.org/tabid/88/itemid/166/Water-Intoxication-in-Infants.aspx Water Intoxication in Infants]</ref>
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| ===Endurance sports=== | | == [[Water intoxication natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
| Marathon [[running|runners]] are susceptible to water intoxication if they drink only water while running. Although sweat is relatively [[hypotonic]] compared with body fluids, marathon runners perspire heavily for long periods, potentially causing their sodium levels to drop when they consume large amounts of fluids to quench their thirst. The replacement fluids may not contain sufficient sodium to replace what has been lost, and this puts them at high risk for water intoxication. Medical personnel at marathon events are trained to immediately suspect water intoxication when runners collapse or show signs of confusion. Properly designed electrolyte-replacement drinks and some sports drinks include [[electrolytes]] that make them roughly isotonic with sweat, which helps to prevent water intoxication.
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| Note that overconsumption of sodium (in drinks or also in food), as well as inadequate intake of water, can cause [[hypernatremia]], a disorder that is nearly the opposite of water intoxication and equally dangerous. Improper use of salt tablets can cause hypernatremia also.
| | == Diagnosis == |
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| ===Overexertion and heat stress===
| | [[Water intoxication history and symptoms|History and Symptoms]] | [[Water intoxication physical examination|Physical Examination]] | [[Water intoxication laboratory findings|Laboratory Findings]] | [[Water intoxication other diagnostic studies|Other Diagnostic Studies]] |
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| Any activity or situation that promotes heavy sweating can lead to water intoxication when water is consumed to replace lost fluids. Persons working in extreme heat and/or humidity for long periods must take care to drink and eat in ways that help to maintain electrolyte balance. Persons using drugs such as [[MDMA]] ("Ecstasy") may overexert themselves, perspire heavily, and then drink large amounts of water to rehydrate, leading to electrolyte imbalance and water intoxication (See the case of Leah Betts). Even people who are resting quietly in extreme heat or humidity may run the risk of water intoxication if they drink large amounts of water over short periods for rehydration.
| | == Treatment == |
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| ===Psychiatric conditions===
| | [[Water intoxication medical therapy|Medical Therapy]] | [[Water intoxication primary prevention|Primary Prevention]] | [[Water intoxication secondary prevention|Secondary Prevention]] | [[Water intoxication cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Water intoxication future or investigational therapies|Future or Investigational Therapies]] |
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| [[Psychogenic polydipsia]] is the psychiatric condition in which patients feel compelled to drink large quantities of water, thus putting them at risk of water intoxication. This condition can be especially dangerous if the patient also exhibits other psychiatric indications (as is often the case), as his or her care-takers might misinterpret the hyponatraemic symptoms.
| | ==Case Studies== |
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| ===Specific disease===
| | [[Water intoxication case study one|Case #1]] |
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| [[Diarrhea]] and [[vomiting]] can result in very large electrolyte losses, and although drinking water will replace lost water, the lost electrolytes may not be adequately replaced, which can result in water intoxication. Replacement fluids for vomiting and diarrhea should be properly balanced to make them isotonic with the fluids lost in these conditions. Special formulations exist for [[oral rehydration therapy]] in these cases.
| | ==Related Chapters== |
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| A great many disorders can affect electrolyte balance, especially disorders of the [[kidneys]]. [[Diuretic]] therapy, mineralocorticoid deficiency, osmotic [[diuresis]] (as in the [[hyperglycemia]] of uncontrolled [[diabetes]]), and the multiple disorders associated with [[AIDS]] are other common causes of electrolyte imbalance, although they do not always produce water intoxication.
| | * [[Electrolyte]]s |
| | | * [[Hyponatremia]] |
| ===Iatrogenic===
| | * [[Hypernatremia]] |
| | | * [[Oral rehydration therapy]] |
| When an unconscious person is being fed intravenously (for example, [[total parenteral nutrition]] or via a [[nasogastric tube]]) the fluids given must be carefully balanced in composition to match fluids and electrolytes lost. These fluids are typically [[hypertonic]], and so water is often co-administered. If the electrolytes are not monitored (even in an ambulatory patient) either [[hypernatremia]] or [[hyponatremia]] may result.
| | * [[Polydipsia]] |
| | | * [[Aquagenous Urticaria]] |
| Some neurologic/psychiatric medications ([[Trileptal]], among others) have been found to cause [[hyponatremia]] in some patients. Patients with diabetes insipidus are particularly vulnerable due to rapid fluid processing.
| | * [[Self-induced water intoxication and schizophrenic disorders syndrome]] |
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| ==Treatment==
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| Mild intoxication may remain asymptomatic and require only fluid restriction. In more severe cases, treatment consists of:
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| * [[Diuretic]]s to increase urination, which are most effective for excess blood volume
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| * [[Saline (medicine)|Saline]] given intravenously to restore [[sodium]] electrolyte levels
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| * [[Vasopressin]] receptor antagonists
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| ==Prevention==
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| Water intoxication can be prevented if a person's intake of water and electrolytes closely matches his or her losses. The body's regulatory mechanisms provide a very generous margin of safety if the two are imbalanced, but some extreme activities (such as heavy, prolonged physical exertion), as well as disease states, can overwhelm or impair these mechanisms. Avoid situations that provoke extreme or prolonged perspiration. Drinking fluids that are specially balanced to replace lost electrolytes can also help to prevent intoxication. Eating regularly can provide needed electrolytes if only normal water is available for rehydration.
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| [[Sports drink]]s are popular among athletes because they provide the necessary [[electrolyte]]s to support extended exercise. They help keep the body balanced and carrying the right amount of fluids. However, not all drinks advertised as sports drinks are suitable for this purpose, and professional advice should be sought for potentially risky situations such as those described above.
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| Note that a person's innate sense of [[thirst]] is more sensitive to overall dehydration than to changes in electrolytes. Thus, it is possible to develop water intoxication while trying to satisfy thirst, if one drinks a great deal of water over a short period. A dangerous drop in electrolytes, such as the hyponatremia that leads to water intoxication, will not have any effect on thirst if one is sufficiently dehydrated.
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| For people suffering from [[dehydration]] due to the heavy perspiration associated with heavy exertion or heat stress, drinking water to rehydrate is much more important than avoiding water intoxication, since the former is extremely common and the latter is rare. One should never avoid drinking water under such conditions; instead, other steps should be taken to ensure that electrolytes are replaced as well, as noted above.
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| ==Notable cases ==
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| * On [[January 12]], [[2007]], [[Jennifer Strange]], a 28-year-old woman and a mother of 3, from [[Rancho Cordova, California]], was found dead in her home by her mother hours after trying to win one of [[Nintendo]]'s [[Wii]] game consoles in [[KDND|KDND 107.9]] "The End" [[radio station]]'s "Hold Your Wee for a Wii" contest, which involved drinking large quantities of water without [[urine|urinating]]. However, no criminal charges were pressed.<ref>{{cite web | url=http://www.msnbc.msn.com/id/16614865/ | title=Woman dies after water-drinking contest | date=[[January 13]] [[2007]] | publisher=[[MSNBC]] | accessdate=2007-05-10}}</ref> The [[Federal Communications Commission]] has launched its own investigation to determine if the station violated the terms of its operating license.
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| * [[Leah Betts]]<ref>{{cite web | url=http://thedea.org/hyponatremia.html | title=Hyponatremia ("Water Intoxication") | publisher=The DEA.org | accessdate=2007-05-10}}</ref> died on the 16th of November 1995 after taking an [[MDMA|ecstasy]] tablet at her 18th birthday party and subsequently drinking too much water; the case received mass media coverage throughout the United Kingdom.
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| * In a much-publicized case of [[Fraternities and sororities|fraternity]] [[hazing]], four members of the [[Chi Tau]] (formerly [[Delta Sigma Phi]]) House at [[California State University, Chico]] pleaded guilty to forcing 21-year-old student [[Matthew Carrington (student)|Matthew Carrington]] to drink excessive amounts of [[water]] while performing [[calisthenics]] in a frigid [[basement]] as part of initiation rites on [[February 2]], [[2005]].<ref>{{cite web | url=http://www.newsreview.com/chico/Content?oid=oid%3A33779 | title=Another death in the family | date=[[2005-02-10]] | first=Mark | last=Lore | publisher=Chico news & review | accessdate=2007-05-10}}</ref> He collapsed and died of [[heart failure]] due to water intoxication.
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| * On [[September 12]], [[1999]], [[United States Air Force|US Air Force]] [[Recruit training|basic trainee]] Michael J. Schindler died of [[hyperthermia|heat stroke]], severely complicated by water intoxication, two days after becoming seriously ill during a 5.8 mile march. The Air Force changed its recruit training procedures as a result.<ref>{{cite news |first=Peter|last=Grier|title=Airman's Death Brings Training Changes|url=http://www.afa.org/magazine/Jan2000/0100world.asp#anchornine|work=Aerospace World|publisher=Air Force Magazine Online|date=January, 2000|accessdate=2007-01-20}}</ref>
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| * [[New Zealand]] [[race walking|race-walker]] [[Craig Barrett (athlete)|Craig Barrett]] collapsed during the last kilometer of the 50 km walk in the [[1998 Commonwealth Games]] in a non-fatal case of water intoxication. {{Fact|date=May 2007}}
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| * Other notable fatalities due to water intoxication include [[Andy Warhol]], [[Anna Wood]], <ref>{{cite web | url=http://www.erowid.org/chemicals/mdma/mdma_health5.shtml | title=Reasons for dispensing with the holding of an inquest | accessdate=2007-05-10}}</ref> [[2002]] [[Boston Marathon]] competitor Cynthia Lucero,<ref>{{cite web | url=http://www.thebostonchannel.com/newscenter5/1610699/detail.html | title=Doctors: Marathoner Died From Too Much Water | date=[[August 13]] [[2002]] | accessdate=2007-05-10}}</ref> and [[Washington, D.C.]] police officer James McBride.<ref>{{cite web | url=http://www.washingtonpost.com/wp-dyn/content/article/2005/08/10/AR2005081001460.html | title=District Officer Dies After Bike Ride: Over-Hydration Cited as Factor | date=[[August 11]] [[2005]] | publisher=[[Washington Post]] | accessdate=2007-05-10}}</ref>
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| ==See also==
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| {{portalpar|Water|Drinking water.jpg}}
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| *[[Electrolyte]]s | |
| *[[Hyponatremia]] | |
| *[[Hypernatremia]] | |
| *[[Oral rehydration therapy]] | |
| *[[Polydipsia]] | |
| *[[Aquagenous Urticaria]] | |
| *[[KDND]] | |
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| ==References==
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| <references />
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| == External links ==
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| *[http://news.bbc.co.uk/2/hi/uk_news/magazine/6263029.stm BBC news story on water intoxication]
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| *[http://waterintoxication.org WaterIntoxication Awareness campaign]
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| [[Category:Electrolyte disturbance]] | | [[Category:Electrolyte disturbance]] |
| [[Category:Intoxication]]
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| [[Category:Psychiatry]] | | [[Category:Psychiatry]] |
| [[Category:Nephrology]] | | [[Category:Nephrology]] |
| | | [[Category:Emergency medicine]] |
| [[ca:Hiperhidratació]]
| | [[Category:Intensive care medicine]] |
| [[de:Hyperhydration]]
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| [[es:Hiperhidratación]] | |
| [[he:הרעלת מים]] | |
| [[nl:Waterintoxicatie]]
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| [[ja:水中毒]]
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| [[zh:水中毒]]
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