Pediatric emergency medicine trisk 2855 2855
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mEq/L/hr for 2 to 3 hours, which should result in clinical improvement.
This can be achieved with the administration of hypertonic 3% saline (513
mEq/L of sodium). In general, 3 mL/kg of 3% saline would be expected to
raise serum sodium by approximately 3 mEq/L. A practical approach is to
administer doses of 3 mL/kg (maximum dose 100 mL) until seizures stop.
After the initial correction is achieved, the goal for the daily correction
remains approximately 12 mEq/L in the first 24 hours (including the initial
emergent correction). Frequent assessment of serum sodium is necessary to
avoid rapid correction, which may lead to the osmotic demyelination
syndrome.
Patients who have asymptomatic hyponatremia and euvolemia do not
require urgent intervention. The care of these patients should be planned
carefully and based upon the underlying diagnosis with the aim of gradual
correction. If hyponatremia is associated with an edema-forming state,
providing supplemental sodium will worsen the state volume excess. The
goal of therapy would be to achieve negative water balance in excess of
negative sodium balance. To achieve this effectively, the underlying
pathophysiology must be considered, although initial water restriction is
generally indicated. Sodium restriction and diuretic therapy may also be
warranted. The treatment of SIADH begins with water restriction, though
this may be insufficient. Some cases of SIADH require the administration
of salt supplements and loop diuretics to achieve the desired negative water
balance, as guided by consultation with a pediatric nephrologist.
Hypernatremia
Hypernatremia can result from an increase in the total body solutes, a
decrease in body water, or a reduction of body water relatively greater than
a concurrent reduction in total body solutes. Protective mechanisms to
prevent the development of hypernatremia include the stimulation of thirst
and the ability to excrete concentrated urine, thereby minimizing free water
loss. For these mechanisms to be effective, there must be adequate access to
and the ability to retain free water. Given the potential for limited access to
water, infants and children with significant developmental delay are
predisposed to hypernatremic dehydration. The causes of hypernatremia
based on total body sodium are outlined in Table 100.6 . Hypernatremia
