What is the next appropriate management for a 21-year-old female with seizure, fever, tachycardia, obtundation, confusion, and hyponatremia after taking ecstasy?

From the FDA Drug Label

Sodium chloride comprises over 90% of the inorganic constituents of the blood serum. Both its ions are physiologically important. Sodium, more than any other ion, determines the osmotic pressure of interstitial fluids and the degree of hydration of tissues Sodium Chloride Injection, USP, 23. 4%, is indicated as an additive in parenteral fluid therapy for use in patients who have special problems of sodium electrolyte intake or excretion.

The next appropriate management for the 21-year-old female with seizure, fever, tachycardia, obtundation, confusion, and hyponatremia after taking ecstasy is to give her IV fluid with 0.9% saline to correct the hyponatremia and hypovolemia, as hypertonic saline is typically reserved for more severe cases of hyponatremia or those with severe symptoms. The patient's hyponatremia and symptoms suggest a need for careful correction of her sodium levels and fluid status. 1 1

From the Research

The patient should be given IV fluid with 0.9% saline for initial volume resuscitation, and hypertonic saline (3% NaCl) should be considered only if the patient has severe symptoms, with close plasma sodium monitoring to prevent osmotic demyelination syndrome. The management of this patient should prioritize correcting hyponatremia gradually, no faster than 8-10 mEq/L in 24 hours, to prevent central pontine myelinolysis, as suggested by 2.

Initial Management

• The patient requires immediate hospitalization with intensive care monitoring.
• Benzodiazepines such as lorazepam 2-4 mg IV should be administered to control seizures.
• Temperature management with antipyretics like acetaminophen 650 mg and external cooling measures is essential.
• Continuous cardiac monitoring is necessary due to tachycardia and risk of arrhythmias.

Hyponatremia Correction

• The use of 3% NaCl solution should be avoided in cases without severe neurologic symptoms, and management should target the underlying causes of hyponatremia, as recommended by 2.
• If severe symptoms are present, hypertonic saline (NaCl 3% 2 ml/Kg over 20 minutes) can be used, with close plasma sodium monitoring, as suggested by 2.
• Increases in sodium concentration should not exceed 8 mmol/l/24h after initial correction, as recommended by 2.

Additional Considerations

• Laboratory tests including complete blood count, comprehensive metabolic panel, creatine kinase, and toxicology screen should be obtained.
• This presentation is consistent with MDMA (ecstasy) toxicity complicated by serotonin syndrome and/or hyponatremia from SIADH or excessive water intake.
• If serotonin syndrome is suspected, cyproheptadine 12 mg orally followed by 2 mg every 2 hours may be beneficial, as seen in similar cases.
• Activated charcoal is not typically helpful as the drug has likely been absorbed.
• The patient requires close neurological monitoring and may need intubation for airway protection if mental status continues to deteriorate.

The most recent and highest quality study 3 supports the safety of peripheral 3% hypertonic saline bolus administration for neurologic emergencies, but this should be considered with caution and only in cases with severe symptoms, emphasizing the need for careful monitoring and gradual correction of hyponatremia.