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| Line 374: |
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}} | | {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| |}} |
| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | D09 |D09=Salt-depleted SIAD}} | | {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | D09 |D09=Salt-depleted SIAD}} |
| {{familytree/end}}
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| </small>
| |
|
| |
| <small>
| |
| {{familytree/start}}$$$$$
| |
| {{familytree | | | | | | | | | A01 | | | | | |A01=Hyponatremia<br>serum sodium < 135 mEq/L }}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | }}
| |
| {{familytree | | | | | | | | | B01 | | | | | |B01=check for '''pseudohyponatremia'''<br>(Hyperglycemia, Hyperlipidemia, Hyperproteinemia, lab errors)}}
| |
| {{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
| |
| {{familytree | | C01 | | | | | | | | | | | |C02|C01=Symptomatic|C02=Asymptomatic}}
| |
| {{familytree | | |!| | | | | | | | | | | | | |!| }}
| |
| {{familytree | | D01 | | | | | | | | | | | |D02|D01=confusion, ataxia, seizures, obtundation, coma, respiratory depression|D02=Determine '''serum osmolality'''<br>Serum Osmolality = (2 x (Na + K)) + (BUN (mg/dL) / 2.8) <br>+ (glucose (mg/dL) / 18) + (Ethanol (mg/dL) /3.7)}}
| |
| {{familytree | |,|^|-|-|-|.| | | | | |,|-|-|-|+|-|-|-|-|.|}}
| |
| {{familytree | E01 | | | E02 | | | | E03 | | E04 | | | E05 |E01=Infuse 3% saline (1 to 2 mL per kg per hour) with goal of increasing serum sodium level by 6 to 8 mEq per L (not to exceed 10 to 12 mEq per L in the first 24 hours or 18 mEq per L in 48 hours) Consider desmopressin, 1 to 2 mcg every four to six hours|E02=Give single intravenous bolus of 100 to 150 mL 3% saline with goal of increasing serum sodium level by 2 to 3 mEq per L; check sodium level every 20 minutes until symptoms resolve; may repeat bolus twice if symptoms do not resolve
| |
| |E03=Normal 275-295 mOsm/kg<br>Isotonic hyponatremia (pseudohyponatremia)|E04=Low <275mOsm/kg<br>Hypotonic hyponatremia|E05=High >295 mOsm/kg<br>Hypertonic hyponatremia}}
| |
| {{familytree | |!| | | | |!| | | | | |!| | | |!| | | | |!| | }}
| |
| {{familytree | |`|-|v|-|-|'| | | | | F01 | | F02 | | | F03 |F01=Assess for hyperproteinuria or hyperlipidemia |F02=Assess volume status|F03=Assess for hyperglycemia, check for mannitol or sorbitol use or recent administration of radiocontrast media }}
| |
| {{familytree | | | G01 | | | | | | | | | | | |!| | | | | | | |G01=Symptom resolution }}
| |
| {{familytree | |,|-|^|-|.| | | | | | | | | | H01 | | | | |H01=Evaluate vital signs, [[orthostatics]], jugular venous pressure, skin turgor, mucous membranes, peripheral edema, and blood urea nitrogen and uric acid levels}}
| |
| {{familytree | I01 | | I02 | | | | | | | | | |!| | |I01=Check serum sodium level every two hours; adjust infusion rate and switch to isotonic saline|
| |
| I02=Determine underlying cause}}
| |
| {{familytree | | |,|-|-|-|-|-|-|-|-|-|-|-|v|-|^|-|-|-|-|-|-|-|-|.| | | | | | |}}
| |
| {{familytree | | J01 | | | | | | | | | | J02 | | | | | | | | | J03 |J01=Hypovolemic (decreased total body water and sodium level)|J02=Euvolemic (increased total body water, normal total body sodium level)|J03=Hypervolemic (increased total body water)}}
| |
| {{familytree |,|-|^|-|-|.| | | | | | | | |!| | | | | | | | | |,|^|-|-|-|-|.| |}}
| |
| {{familytree | K01 | | K02 | | | | | | | K03 | | | | | | | | K04 | | | | K05 |K01=Urinary sodium > 20 mEq per L|K02=Urinary sodium < 20 mEq per L|K03=Urinary sodium usually > 20 mEq per L|K04=Urinary sodium < 20 mEq per L|K05=Urinary sodium > 20 mEq per L}}
| |
| {{familytree | |!| | | |!| | | | |,|-|-|-|^|v|-|-|-|-|.| | | | |!| | | | |!| | | |}}
| |
| {{familytree | L01 | | L02 | | | L03 | | | L04 | | | L05 | | | L06 | | | L07 |L01
| |
| =Renal loss (from diuretics or mineralocorticoid deficiency)|L02=Extrarenal loss (fromv omiting, diarrhea,third spacing, or bowel obstruction)|L03=Urinary osmolality > 100 mOsm per kg|L04=Urinary osmolality < 100 mOsm per kg|L05=Variable urinaryosmolality|L06=Heart failure,cirrhosis, nephrosis,hypoalbuminemia|L07=Renal failure}}
| |
| {{familytree | M01 | | M02 | | | M03 | | | M04 | | | M05 | | | M06 | | | M07 |M01=Isotonic saline(see Table 1for specifitreatments)|M02=Isotonic saline(see Table 1for specifictreatments)|M03=Syndrome ofinappropriate antidiuretichormonesecretion, hypothyroidism,adrenal insufficiency,stress, drug use|M04=Primary polydipsia,low solute
| |
| intake (beer potomania syndrome)|M05=Resetosmostat|M06=Diuresis, fluid andsodium restriction(see Table 1 for specific treatments)|M07=Fluid and sodium restriction, dialysis
| |
| (see Table 1 for specific treatments)}}
| |
| {{familytree | | | | | | | | | | |!| | | | |!| | | | |!| | | | | | | | | | |}}
| |
| {{familytree | | | | | | | | | | N01 | | | N02 | | | N03 | | | | | | | | | |N01=Fluid restriction(see Table 1for specifictreatments)|N02=Fluid restriction(see Table 1for specific treatments)|N03=Fluid restriction(see Table 1for specifictreatments)}}
| |
| {{familytree/end}} | | {{familytree/end}} |
| </small> | | </small> |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2] Saeedeh Kowsarnia M.D.[3]
Overview
Hyponatremia must be differentiated from other diseases that cause muscle weakness or cramps, oliguria, vomiting or diarrhea and seizures.
Differentiating Hyponatremia from other Diseases
| Disease
|
Clinical manifestations
|
Paraclinical Findings
|
| Symptoms and Signs
|
Lab Findings
|
| Muscle weakness/ Cramps
|
Seizures
|
Oliguria
|
Vomiting/ Diarrhea
|
Volume status
|
JVP
|
Edema
|
Crackles
|
Ascites
|
Tachycardia
|
Hypotension
|
Dry mucous membranes
|
Urine Analysis
|
Serum Osmolality
|
ADH levels
|
| Urine Na
|
Urine Osm
|
FeNa
|
| Renal failure
|
+/-
|
+/-
|
+/-
|
-
|
Hypervolemic
|
+
|
+
|
+
|
+
|
-
|
-
|
-
|
>20
|
-
|
>1%
|
-
|
Normal or ↑
|
| Congestive heart failure
|
+/-
|
+/-
|
-
|
-
|
Hypervolemic
|
+
|
+
|
+
|
+
|
-
|
-
|
-
|
<10
|
-
|
<1%
|
-
|
↑
|
| Cirrhosis
|
+/-
|
+/-
|
-
|
-
|
Hypervolemic
|
+
|
+
|
+
|
+
|
-
|
-
|
-
|
<10
|
-
|
<1%
|
-
|
↑
|
| SIADH
|
+/-
|
+/-
|
-
|
-
|
Euvolemic
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
>100
|
-
|
-
|
↑
|
| Hypothyroidism
|
+/-
|
+/-
|
-
|
-
|
Euvolemic
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
>100
|
-
|
-
|
↑
|
| Adrenal insufficiency
|
+/-
|
+/-
|
-
|
-
|
Euvolemic
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
>100
|
-
|
-
|
↑
|
| Psychogenic polydipsia
|
+/-
|
+/-
|
-
|
-
|
Euvolemic
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
<100
|
-
|
-
|
↑
|
| Beer drinker's potomania
|
+/-
|
+/-
|
-
|
-
|
Euvolemic
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
<100
|
-
|
-
|
↓
|
| Pregnancy
|
+/-
|
+/-
|
-
|
-
|
Euvolemic
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
Variable
|
-
|
-
|
↓
|
| Anorexia (Chronic malnutrition)
|
+/-
|
+/-
|
-
|
-
|
Euvolemic
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
-
|
Variable
|
-
|
-
|
-
|
| Diuretic induced hyponatremia
|
+/-
|
+/-
|
+
|
-
|
Hypovolemic
|
-
|
-
|
-
|
-
|
+
|
+
|
+
|
>20
|
-
|
>1%
|
-
|
-
|
| Non oliguric ATN
|
+/-
|
+/-
|
-
|
-
|
Hypovolemic
|
-
|
-
|
-
|
-
|
+
|
+
|
+
|
>20
|
-
|
>1%
|
-
|
-
|
| Diseases causing 3rd spacing (Pancreatitis, SBO)
|
+/-
|
+/-
|
+
|
+/-
|
Hypovolemic
|
-
|
-
|
-
|
-
|
+
|
+
|
+
|
<10
|
-
|
<1%
|
-
|
-
|
| Gastroenteritis
|
+/-
|
+/-
|
+
|
+
|
Hypovolemic
|
-
|
-
|
-
|
-
|
+
|
+
|
+
|
<10
|
-
|
<1%
|
-
|
-
|
| Sweating
|
+/-
|
+/-
|
+
|
-
|
Hypovolemic
|
-
|
-
|
-
|
-
|
-
|
+/-
|
+/-
|
<10
|
-
|
<1%
|
-
|
-
|
| Cerebral salt-losing syndrome
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
<nowiki>
| | | | | | | | Serum Na ≤ 135 meq/L | | | | | |
|
| | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | Check for: |
|---|
• Serum osmolality
• Urine osmolality
• Urea
• Glucose
• Urine chloride
• Urine Na |
| | | | | |
|
| | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | |
| Normotonicity
275–295 mOsm/kg |
|---|
•Hyperlipidemia
•Hyperproteinemia
•Glycine |
| | | | | Hypertonicity
> 295 mOsm/kg |
|---|
• Glucose
• Mannitol
• Glycine |
| | | | | Hypotonicity
<275 mOsm/kg |
|
| | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | |
| | | | | | | | | | | UOsm < 100mOsm/kg | | UOsm > 200mOsm/kg | | | UOsm 100–200mOsm/kg |
|
| | | | | | | | | | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | | | | Conditions |
|---|
•Polydipsia
•↓ solute excertion
(Beer potomania
,Tea & toast diet) |
| | | | | | | | | Conditions |
|---|
•Polydipsia
•↓ solute excertion
(Beer potomania
,Tea & toast diet)
•Rule out SIAD |
|
|
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | Hypovolemia
Based on history & physical exam | | | | | | | | Hypervolemia | | | | | | | | | | | Euvolemia | |
|
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| UNa < 30 mEq/L | | Variable UNa | | UNa > 30 mEq/L | | UNa < 30 mEq/L | | UNa > 30 mEq/L | | Variable UNa | | UNa < 20
mEq/L | | > 20 UNa < 40 mEq/L | | UNa > 40 mEq/L |
|
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
|
| | Extrarenal losses |
|---|
Vomiting (Ucl ↓)
Diarrhea
Pancreatitis
Sweating
Small bowel obstruction |
| | Variable UNa
Diuretic use
Discontinue diuretics if UNa is still abnormal | | | Renal losses |
|---|
Osmotic diuresis (glucose, urea,bicarbonaturia)
Salt-Iosing nephropathy
Addison disease
CSW |
| | | Conditions |
|---|
•Heart failure
•Liver disease
•Nephrotic syndrome |
| | | Conditions |
|---|
•Chronic kidney disease
•Diuretic use in:
Heart failure
Liver disease
Nephrotic syndrome |
| | Discontinue diuretics if PNa normalize it's not SIAD if it's not normalized | | Probable hypovolemia | | Hypovolemia or euvolemia | | Probable euvolemia
SIAD
Cortisol deficiency
Hypothyroidism |
|
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | Administer 0.9% saline | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | |
| Normalize PNa | | | | | | | | | | | | | | | | | | | | | | | | | Administer 1–2 L 0.9% saline | | | | | | |
|
| | | | | | Failure to normalize PNa | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | |
| Hypovolemia | | | | | | | | | | | | | | | | | | PNa decreases or no change | | | | | | | | | | | | | PNa increases |
| | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | |
| | | Decreasing UOsm | | No change in UOsm but UNa increases | | | | | | | | | | | SIAD | | | | | | | No change in UOsm but UNa increases | | | Decreased UNa |
| | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
|
| | | Hypovolemia | | Salt-depleted SIAD | | | | | | | | | | | | | | | Hypovolemia | | | Decreasing Uosm | | | Administer additional saline |
| | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | No change in UOsm
but UNa increases |
|
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Salt-depleted SIAD |
|
References
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Template:WS