Category Archives: Overview

Hyponatremia: The Most Common Electrolyte Abnormality…Ever

When learning anything, we should always ask ourselves two  important questions:

1) Does this make sense to me?

2) Is this relevant to me?

Obviously you won’t be able to retain any of the information you learn if you don’t even understand it. And you’re even less likely to retain it if it has no relevance to your life.

I realized I needed to post something on Hyponatremia when I had to go back to my Mass Gen hyponatremia algorithm flow chart for the hundreth time that day all the while knowing that in 5 minutes I’d forget it again. So I sat down and decided to break it down so it made sense to me.

That having been said, I present to you a simplified understanding of the management of hyponatremia, the most common electrolyte abnormality…ever.

So why is this important to you? In other words what is the relevance?

1) It’s common. In fact it is the most common electrolyte abnormality with up to 30% of hospitalized patients developing it, mostly in elderly.

2) Its deadly dangerous. (Anytime you have death as a potential outcome there is something to look out for.) The risk of morbidity and mortality increases with the severity of hyponatremia in almost every known disease state.

3) Possible treatments vary greatly from each other. They vary so greatly that they are in fact opposites (i.e. giving fluids vs. restricting fluids) Choosing the wrong treatment option can lead to above mentioned “death” scenario.

Please make sure he never suffers at the hands of hyponatremia:

The Basics:
Definition: <135 mEq/L, severe if < 125 mEq/L
Normal range: 135-145 mEq/L

One key point to remember here: The extracellular sodium concentration is more indicative of water balance than it is of total body sodium content. Essentially, the serum sodium value says more about how much water is in blood vessels than it does about the actual sodium content. Think dilution.

Signs/Symptoms: It begins very nonspecific and mild with headaches and irritability and progresses to nausea and vomiting, some mental slowing, unstable gait/falls, confusion/delirium, and disorientation. Then to the more severe, what you don’t want to see in your patients: stupor/coma, convulsions, respiratory arrest and…I would put death here but at that point its not a very helpful symptom in terms of management. In general, the more severe the symptom the more quickly and aggressive you need to treat.

Here is what most med students, and very likely most interns think of when going through Hyponatremia (sorry for the blurred font)

Just so you’re not that intern. Here are the Big Picture Steps for understanding Hyponatremia:

Hyponatremia Management: The BIG Picture

OVUM (for those of you mnemonic freaks out there, I’m one too.)
Osmolality + Volume status + Urine = Management!

1) Check Serum Osmolality: Why? To rule out causes of “false” hyponatremia such as an increase in protein, lipids, glucose, mannitol, or glycine (secondary to urolgic or gynecologic procedures). Essentially we are asking, is this “true” or not?

Question: Why do lipids, glucose, protein, mannitol affect serum sodium values?
Non sodium solutes such as glucose cause fluid to shift into the vasculature essentially causing a dilution of serum sodium concentration. Osmotic pressure baby. What this does is give the appearance of a drop in sodium. Remember this formula?  Corrected Serum Osmolality = 2Na + Glucose/18 + BUN/2.8. Well, now you know why BUN and Glucose are in there. There are strong solutes.

2) Check Volume status: Why? Whether fluid is retained or not helps us tentatively approach the etiology (Is is due to cirrhosis, heart failure, nephrotic syndrome? Or is it due to diarrhea, vomiting,  diuretic use?) Then we can decide which treatment options to consider: To give water or not to give water, that is the question…

Whether ’tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles
And by opposing end them.

Take arms I say, take arms! Arms filled with bags of saline…unless of course the patient has SIADH.

Question: How do we determine volume status? This is done clinically. (ie. check for postural hypotension, JVP, tachycardia, skin turgor, signs of swelling/edema.)

3) Check Urine Osmolality and Urine Na: Why? To find out if the kidneys are the culprit. If Urine Na >20 → most likely yes.

4)Management/Treatment: Ultimately you either replace fluids or restrict them. The correct decision needs to be made to avoid unwanted outcomes. Additional info along the way can lead you to discovering the underlying pathology. An example would be finding out that the Urine Osmolality is >100 mOsm/kg suggesting an SIADH picture (ADH causes you to retain water by activating aquaporin channels in the collecting ducts so naturally the Urine Osmolality would be higher). Might there be a pulmonary or CNS lesion we are unaware of? This can lead to a crucial discovery for the patient’s care.

Question: Why are patients often euvolemic in SIADH while also excreting so much sodium?
In Syndrome of Inappropriate Antidiuretic hormone Hypersecretion, you have just that – hypersecretion of ADH, causing retention of water at the level of the collecting ducts. The thing is, the body’s Osmoregulatory systems are still working fine. It senses and increase in fluid and tries to get rid of the excess as best as it knows how: by getting rid of sodium, hoping that water will follow. Which of course it doesn’t. Hence patients tend to either be euvolemic or slightly hypervolemic and hyponatremic. Voila!

One last major point to consider during the initial workup is if this acute or chronic. An acute episode of hyponatremia is defined as being <48 hours and evidenced by neurological sequelae, since the brain has much less time to adapt to the osmotic differential.

The long and the short of it (The Review)

When being presented with a patient that is hyponatremic I realize that I first need to know whether this hyponatremia is “true” or not which is where serum osmolality comes in. Second, I need to know whether I should be preparing to give this guy fluids or restrict fluids. This is where knowing the volume status comes in. And finally, checking his Urine tells me whether I am dealing with something kidney related or not. Instead of relying on a blurred mental image of the hyponatremia algorithm I can actually think it through in a way that makes sense. Which is why it’ll stick this time around.

Train yourself to review

Did that make sense? Was it relevant to you? I hope you can answer yes to both questions. Try to get into the habit of reviewing material you’ve just read especially when studying for the boards or for exams. The review will help you to realize if there was something you didn’t really understand as well as help your brain file it away appropriately, having made the important connections and associations. It literally can take only 5 seconds for a big picture review.

Dive back into those physio and biochem books if you have to and make sure you get the basics. As a resident, these concepts are foundational and inform your decision making.

Enjoy your sodium!

Drinking too much water

One interesting phenomenon that I think we as clinicians will be seeing more of is hyponatremia secondary to drinking too much water. You’ll see this mainly in athletes training for a marathon, a triathlon, or just exercising really. The excess water intake essentially dilutes serum sodium before the body has time to excrete the excess. The treatment for water intoxication is just fluid restriction in mild cases, and in severe cases the use of diuretics and/or vasopressin receptor antagonists such as the Vaptans.

Helpful Algorithms
(Click on the images to make them bigger)

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Overview: Behavioral

There’s not much I’m going to say here aside from the books I used and some studying advice. The reason being that Behavioral is actually not a conceptually difficult subject, it just needs to be given some attention. DO NOT brush aside Behavioral Science. I have been told this many times before myself and still I did not give it as much time as I should have. I was surprised to see how many Behavioral questions there were on my exam. I mainly saw questions on legal issues and how to deal with non compliant or difficult patients. I also remember having one question that dealt with a patient with different cultural beliefs.

The sources I used to tackle this were 1) Kaplan’s Lecture Notes 2) High Yield Behavioral Science by Fadem (3rd ed.) and 3) UsmleWorld Qbank.

A quick note about the Kaplan notes: There are a series of rules for dealing with patients and with legal issues towards the end of Kaplan’s Behavioral notes that I found amazing. The reason they work so well is because they give you a few solid principles with which to apply to an infinite amount of scenarios. For example, one of the rules Kaplan created for the physician-patient relationship is “Never pass off your patient to someone else”. I can’t tell you how many times I saw a behavioral question on the test with this as one of the answer choices. An example of this would be to refer your patient to a specialist or offering to help your patient see a counselor for their specific issue, etc. I remember in the past I would seriously consider this as an option(making the question more difficult for me). After reading Kaplan’s “rules,” the behavioral questions are less grey and more black and white.

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Overview: Biostatistics

Biostatistics was very confusing for me at first but I made it a point to understand it. It was easy enough to memorize the equations but I really wanted to know what they all meant, how it all came together. Getting to that place of really understanding and feeling comfortable with the material took a combination of videos (from Kaplan and from YouTube), High Yield Biostatistics by Glaser, along with the new Subject Review Series that UsmleWorld came out with. Throughout all this I was doing Biostat questions from the UsmleWorld Step 1 Qbank. I did it in this order (roughly from simplest to more challenging):

1. Kaplan Biostats Videos/YouTube Videos

2. HY Biostats

3. UsmleWorld Biostats Subject review

4. UsmleWorld Step 1 Qbank

The UW Biostat subject review was by far the one that brought it all home for me. Granted this was probably because I had gained some basic understanding already from the previous videos and Glaser’s book. The subject review is nicely organized by main sections and organized in order that builds on itself. I definitely recommend purchasing it. If you only pick one thing to do I suggest doing that, because honestly the Kaplan books and videos do not cover everything you need to know for potential Step 1 questions.

Here’s an example of a video that was helpful for me. Khan academy actually has several videos out on YouTube for Statistics. I would watch these during my breaks and found that the presenter clarified some things I never really understood. You might or might not like his style of teaching. Enjoy!

Here are some topics I feel are high yield for the Step 1 exam:

  • Sensitivity (snout)
  • Specificity (spin)
  • Positive predictive value, PPV (remember this depends on prevalence)
  • Negative predictive value, NPV (also depends on prevalence)
  • Relative Risk (remember to use in cohort studies)
  • Odds Ratio (remember to use in case-control studies)
  • Confidence Intervals
  • Setting a cutoff point on normal distributions (classic example is the fasting blood glucose cutoff for diabetes)
  • Attributable Risk
  • Number Needed to Treat
  • P value (probability that the null hypothesis is correct)
  • Correlation coefficient (describes a linear association does NOT necessarily imply causation)
  • Variability or the percent of variability (remember to square the correlation coefficient)
  • Which test to use chi-square? correlation? t-test? ANOVA?
  • The biases: length-time, lead-time, confounding, selection, etc.

All that said, I am sure I left out some potential test question topics. What I left out however, I’m sure the UW subject review will cover. One thing I do want to cover is something I personally had difficulty understanding for the longest time and it was only recently that it became clear and that is the difference between relative risk and odds ratio. Risk and Odds, they always sounded like the same thing.

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A quick word about Embryology

Embryology is a very visual subject. I assure you that words can never do justice to this field. Thank God for the glory of technology. If Embryology is proving difficult for you (It was for me) I strongly urge you to look at the Indiana University Animations. They were beyond helpful for me.

Oh, and don’t opt out of doing the surveys. They are just as beneficial for you as they are to the school. They give you a good sense of where you currently stand with your knowledge and when you retake it after the animation you’ll be surprised at how much you learned in a few minutes.

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