Pediatric emergency medicine trisk 1897 1897
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The underlying cause of SIADH, such as meningitis or pneumonia, should be treated when
possible; successful treatment is usually accompanied by remission of inappropriate water
retention.
TABLE 89.9
CRITERIA FOR DIAGNOSIS OF SYNDROME OF INAPPROPRIATE
ANTIDIURETIC HORMONE SECRETION
Hyponatremia, reduced serum osmolality
Urine osmolality inappropriately elevated (a urine osmolality <100 mOsm/kg usually
excludes the diagnosis)
Urinary Na+ concentration that is excessive in comparison to the degree of hyponatremia
(usually >18 mmol/L)
Normal renal, adrenal, and thyroid function
Absence of volume depletion (euvolemic to hypervolemic state)
Asymptomatic or Mildly Symptomatic Children
Asymptomatic or mildly symptomatic children are best treated by rigorous fluid restriction.
Fluid input should be sharply limited, often below insensible loss (to 800 cc/m2), until the
[Na+ ] and osmolality begin to rise. If the initial [Na+ ] is less than 125 mEq/L, all fluids
must be withheld.
Frequent measurements of plasma electrolytes, glucose, and osmolality, as well as close
monitoring of fluid input and output, are essential. As the serum [Na+ ] rises and urine
osmolality falls, the rate of fluid administration can be gradually increased.
The child with chronic or recurrent episodes of SIADH may require treatment with a drug in
the “vaptan” class (tolvaptan, conivaptan), which blocks vasopressin binding to its receptor.
Pediatric dosing parameters have not yet been formally established. Consultation with a
pediatric endocrinologist should be conducted to guide dosing.
Clinical Indications for Discharge or Admission
Admission is indicated for children who are symptomatic, or are newly diagnosed with
hyponatremia, until a reassuring trajectory has been established.
HYPERPARATHYROIDISM
Goal of Treatment
The major ED treatment goal is to address clinical effects of severe hypercalcemia and
hypophosphatemia while trying to correct these electrolytes.
CLINICAL PEARLS AND PITFALLS
