PANCE - Hyponatremia Management

Here are key facts for PANCE from the Acute Hyponatremia Management tutorial, as well as points of interest at the end of this document that are not directly addressed in this tutorial but should help you prepare for the boards. See the tutorial notes for further details and relevant links.

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1. Timeframe definition: From the time of development section, acute hyponatremia develops within last 48 hours, while chronic hyponatremia develops over longer than 48 hours. 2. Neurological manifestations: From the key symptoms section, acute hyponatremia presents with cognitive symptoms (confusion, seizures, coma), motor symptoms (ataxia, tremor), and gastrointestinal symptoms (nausea, vomiting). 3. Physical examination findings: From the key physical exam findings section, look for peripheral edema from volume overload and cerebral edema manifesting with neurological signs of coma. 4. Severity grading: From the severity section, hyponatremia is classified as severe (<120 mEq/L), moderate (120-130 mEq/L), or mild (130-135 mEq/L). 1. Treatment threshold: From the treatment indication section, intervention is indicated when sodium is <130 mEq/L in acute cases. 2. Correction target: From the general goal section, aim for 5 mEq/L increase over the first few hours while avoiding over-correction over 24 hours. 3. Emergency treatment protocol: From the symptomatic section, administer rapid 100 mL 3% hypertonic saline infusion over 10 minutes to any acutely symptomatic patient with cerebral edema concerns. 4. Monitoring requirement: From multiple sections, check sodium levels hourly during correction to avoid complications.

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1. Common acute scenarios: From the common acute causes section, recognize IV fluid overload in surgery and water intoxication (marathon runners, psychotic polydipsia) as frequent causes. 2. Medication-induced cases: From the additional management section, identify thiazide diuretics as potential contributors to hyponatremia. 3. SIADH triggers: From the additional management section, assess for recent surgery, pain, and certain medications as potential causes of SIADH. 1. Asymptomatic management: From the asymptomatic section, use 50 mL of 3% saline, check sodium hourly, and repeat bolus if needed for patients without symptoms. 2. Autocorrecting cases: From the autocorrecting section, if hyponatremia is already autocorrecting from water diuresis, no saline bolus is needed - just monitor hourly targeting a 5 mEq/L increase. 3. Treatment modification criteria: From the autocorrecting section, if sodium drops instead of increases during monitoring of an autocorrecting case, administer the 50 mL 3% saline bolus. 1. Fluid restriction: From the additional management section, stop other IV fluids to avoid worsening the hyponatremia and restrict any electrolyte-free water intake. 2. Underlying cause investigation: From the additional management section, look for any contributing factors and possible SIADH causes. 3. SIADH-specific therapy: From the additional management section, consider additional treatments (salt tablets, loop diuretics) in SIADH cases. 4. Management principle: From the general goal section, the approach should be to treat rapidly early, monitor closely hourly, then level off to give the brain a chance to adapt and avoid osmotic demyelination. 5. Safety monitoring: From the general goal section, the primary concern is avoiding over-correction to prevent osmotic demyelination.

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Below is information not explicitly contained within the tutorial but important for PANCE. 1. Diagnostic approach: Using serum and urine osmolality, urine sodium, and volume status assessment to determine underlying cause. 2. Differential diagnosis: Distinguishing true hyponatremia from pseudohyponatremia and factitious hyponatremia. 3. Special populations: Modifications for elderly, patients with heart failure, cirrhosis, or renal failure. 1. Emergency department protocols: Standardized approaches to hyponatremia in acute care settings. 2. Inpatient-outpatient transition: Follow-up recommendations and monitoring after initial correction. 3. Patient education: Teaching about medication adherence, fluid intake monitoring, and symptom recognition. 4. Interprofessional coordination: Working with nephrology, neurology, and critical care in complex cases.