>> BY DENNIS EDGERLY, EMT-P
DILEMMAS IN DAY-TO-DAY CARE
‘NOT ACTING RIGHT’
Providers treat patient with hyponatremia due to a brain tumor
The patient’s wife called 9-1-1 because her husband was acting drunk. When you arrive on scene, a
middle-aged woman meets you at the door
and tells you she’s concerned about her husband. She came home from a weekend business trip and found him “not acting right.”
You ask for clarification, and she tells you
he is confused and having difficulty walking. She doesn’t think he’s drunk because
he’s only had one beer, but says, “He is sure
After assuring the wife you will take care
of her husband, you and your partner walk
into the living room where he’s sitting.
You find a 46-year-old male sitting on the
couch. He looks at you and nods his head
when you say, “hello,” but doesn’t speak.
A quick physical exam reveals no signs
of trauma. He appears to be moving all
extremities but is unable to follow commands when you attempt to perform a Cincinnati Stroke Scale assessment.
You note no facial droop or drooping
of the eyelid, which is called ptosis. The
patient’s skin is pink, warm and dry, and his
pupils are equal and reactive at 4 mm. He
doesn’t appear to be in pain or respiratory
distress. His pulse is 72 and regular. Blood
pressure is 146/82 and respirations are 18
and uncompromised. A finger-stick blood
glucose level reads 106 mg/dL. There’s a
can of beer sitting next to him, but it’s
The patient’s wife tells you her husband seemed normal when she spoke with
him this past evening but he was tired
and going to bed early. She tells you he is
healthy and takes no medications on a regular basis. A little bewildered, you and your
partner place the patient on a stretcher and
into the ambulance.
During transport, you establish an IV
and begin a reassessment when the patient
develops a tonic-clonic seizure. The seizure
PHOTO JEFFREY MAYES
Hyponatremia is commonly found at endurance events where patients sweat excessively.
lasts about 45 seconds. The patient now
responds only to noxious stimuli with
moaning and withdrawal. You suction his
airway, apply oxygen and ask you partner
to step it up to an emergent transport.
Sodium is the primary extracellular
ion. Normal values are 135–145 mEq/dL.
Hyponatremia is defined as sodium levels
less than 135 mEq/dL, with levels less than
125 mEq/dL being considered severe. 2
As you transfer the patient, you ask the
emergency physician what she thinks is the
cause. She tells you she needs to wait for
When you follow up later, she tells you
the patient’s sodium level was 118 mEq/L.
The patient was hyponatremic because he
has a tumor on his posterior pituitary gland
that’s causing an increased production of
antidiuretic hormone (ADH), resulting in a
dilution of his sodium levels. This is called
syndrome of inappropriate anti-diuretic
hormone (SIADH), which has many underlying causes in addition to hyponatremia.
When sodium levels drop, there’s a change
in osmolarity that causes fluid to move into
cells. This causes cellular swelling, which
is most concerning in the brain and is the
cause of many of the symptoms. If hyponatremia develops slowly, the body may have
the ability to compensate, and patients may
be asymptomatic even with sodium levels as
low as 115 mEq/dL. 1 However, patients with
acute hyponatremia can be critical.
Sodium concentration can be depleted
in a couple of ways. In hypovolemic hyponatremia, a body has lost too much sodium
in relation to water loss. This can occur with
excessive sweating as seen with endurance
sports like marathons, use of such diuretics as thiazide diuretics, and third spacing of
fluid, as is seen with burns.
The other way is to dilute the body’s
sodium concentration with too much
The brain tumor that caused hyponatremia
in this case may not be commonplace, but
hyponatremia is one of the most common
electrolyte imbalances seen in the field. 1