What is the most appropriate management for a patient with hyponatremia (serum sodium level of 130 milliequivalents per liter (mEq/L)) and symptoms of headache, confusion, and disorientation after participating in a marathon?

From the Guidelines

The most appropriate management for this patient is option C: 100-mL bolus of 3% saline. This 22-year-old marathon runner is presenting with symptoms consistent with exercise-associated hyponatremia (EAH), characterized by confusion, headache, and a serum sodium level of 130 mEq/L. According to the study by G. T. Chiampas and A. V. Goyal 1, current consensus guidelines recommend up to three 100 mL boluses of 3% sodium chloride (NaCl) solution spaced at 10-min intervals to correct symptoms in more severe cases of EAH, with presenting symptoms of confusion. The patient's confusion indicates a more severe case of EAH, necessitating the use of hypertonic saline to rapidly correct the sodium level and alleviate symptoms. Key points to consider in the management of this patient include:

• The patient's serum sodium level is 130 mEq/L, indicating hyponatremia
• The patient is confused, indicating a more severe case of EAH
• Hypertonic 3% saline is recommended for severe hyponatremia with significant neurological symptoms, such as confusion 1
• Fluid restriction (option A) would be inappropriate as the patient may also be dehydrated from the marathon, and isotonic saline (option B) may not be sufficient to rapidly correct the sodium level in a severe case
• No treatment (option D) would be inadequate given the patient's symptomatic hyponatremia.

From the Research

Management of Hyponatremia

The patient presents with symptoms of hyponatremic encephalopathy, including headache, confusion, and disorientation, with a serum sodium level of 130 mEq/L. The most appropriate management for this patient would be:

• Administration of a 100-mL bolus of 3% saline, given over 10 minutes, to quickly treat cerebral edema, as recommended by 2
• This approach is supported by 3, which found that bolus infusion of hypertonic saline resulted in more rapid elevation of plasma sodium concentration and improvement in Glasgow Coma Scale
• Additionally, 4 compared the efficacy and safety of 100 and 250 mL NaCl 3% rapid bolus therapy and found that both were effective, but the 250 mL bolus was more effective in increasing serum sodium levels

Rationale for Choice

The choice of administering a 100-mL bolus of 3% saline is based on the patient's symptoms of hyponatremic encephalopathy and the need for rapid correction of serum sodium levels to prevent further cerebral edema. This approach is supported by the evidence from 2, 3, and 4, which demonstrate the effectiveness of hypertonic saline in treating symptomatic hyponatremia.

Considerations

It is essential to monitor the patient's serum sodium levels closely and adjust the treatment as needed to avoid overcorrection, which can lead to osmotic demyelination syndrome, as noted in 2 and 4. The patient's clinical status, including symptoms and Glasgow Coma Scale, should also be closely monitored to assess the effectiveness of treatment.