Hypertonic saline

[DesertMedic66]

I can think of a couple off the top of my head. Lake Mead recreational area, Joshuah Tree, and all those wilderness areas that BLM runs. Most of them will post as a Law Enforcement position but it's dual role. Might have to put in some years as a seasonal Law Enforcement but once you hit gs-6 or have preference points Or LE trained your offered full time. Also plenty of colleges offer a Park Service Law Enforcement course which gives you the certification to go out and get a job as a certified LE. Also Federal Law Enforcement Training Center will get you the needed certification to get the job. They make a point of making it hard to get a joB

Lake Mead is 6 hours away for me which is not something I would be able to afford. Joshua tree rangers are not ALS.

The rangers in the Ocotillo Wells area are not ALS. The "medical responders" out there are called "desert lifeguards". In the summer months they are assigned to lifeguard duties and in the winter they are put at the off-road areas.

The rangers in the San Jacinto mountains are EMR/EMT and not ALS (we meet up with them very often)

 

[E tank]

Based off MDCalc 3% NS @ 103 ml/hr will increased serum sodium by 1 mmol/hr in an elderly 80kg Male with a sodium of 115. 1 mmol/hr is aggressive but may be appropriate if severely symptomatic. But I agree that 100ml is unlikely to cause issues, it would take more than that.

Yah...I never know what to make of those calculators. Maybe its the extreme example of 115. But in clinical practice where there are many multiples of dynamics occurring in the critically ill, sometimes experience and theory don't match up...as an example, in the rare circumstance of giving several amps of bicarb, say three to five, what you give there is essentially 2 % NaCl and the sodium bumps several points in a very short period of time, such that you need to be careful of creating a hypernatremia.

 

[Alan L Serve]

Let's leave the argument over "bolus" behind and focus on the actual volume over time. I feel rather confident that 100mL over 10 minutes is OK only for severe hyponatremia. Higher volume or faster infusion is likely to cause OSMOTIC DEMYELINATION.

I deleted cerebral edema as it was clearly incorrect. In its rightful place now sits ODS.

Previous observational studies reported from our institution have shown that ODS can usually be avoided in severely hyponatremic patients by limiting correction rates to no more than 12 mEq/L in 24 h and 18 mEq/L in 48
Hypertonic Saline for Hyponatremia: Risk of Inadvertent Overcorrection

http://cjasn.asnjournals.org/content/2/6/1110.full

 

[LaAranda]

Great discussion all around. Here's the 3% protocol -- thanks for your patience.

Indications: Serum sodium <135 mmol/L with ALOC or seizure activity; Serum sodium ≤128 Note: Hyponatremia needs to be acute onset (excessive fluid intake within the past 24 hours)
Contraindications: Suspected chronic hyponatremia (CHF, liver cirrhosis)
Dosage: 100ml 3% saline bolus x3 q 10 minutes using burette set. Administer each bolus with drip chamber wide open. Administer all 3 boluses. Check 2nd iStat after full dose administered.
Note: Rapid correction of hyponatremia that is not acute can cause permanent damage of the nervous system. Conditions that can cause chronic hyponatremia include heart failure, cirrhosis, renal failure, cancer, adrenal insufficiency, and certain medications. A thorough history is the best means of determining the cause of the patient’s hyponatremia. Generally, a history of ingesting large amounts of unmixed water throughout the day in conjunction with physical exertion suggests acute hyponatremia. Be sure to obtain follow-up iStat values after administration of hypertonic saline. Every 100mL of hypertonic saline will correct a patient’s serum sodium by 1-2 mEq/L.
Procedure:

• A... Fill burette to 100mL.
• B. Open lower roller clamp wide open.
• C. Allow full 100mL bolus to be administered (should take 2-4 minutes).
• D. Close lower roller clamp.
• E. Open upper roller clamp and refill burette to 100mL.
• F. Administer second bolus 10 minutes after first bolus was begun.
• G. Administer third bolus 10 minutes after second bolus was begin.
• H. All three boluses (300mL total) should be given q 10 minutes, making the total administration approximately 30 minutes long.

So the the actual infusion rate is 100ml/~3min, q 10 min.