A 72-year-old woman is confused with sodium 114 mmol/L. How would you manage her?

Question

Accepted Answer

A sodium of 114 with confusion is severe symptomatic hyponatraemia. I would perform an urgent ABCDE assessment to ensure airway protection and haemodynamic stability, then clarify whether this is acute or chronic by reviewing previous bloods, as that significantly affects management and overcorrection risk. I would assess volume status clinically for hypovolaemia, hypervolaemia or euvolaemia. If she has severe symptoms — reduced consciousness or seizures — I would consider cautious 3% saline 100 ml over 10 minutes, repeated if necessary, targeting an initial rise of 4–6 mmol/L to reduce cerebral oedema risk. Simultaneously I would send paired serum and urine osmolality, urine sodium, TFTs and cortisol, and review medications (diuretics, SSRIs, other SIADH-associated drugs). Euvolaemic, low serum osmolality with inappropriately concentrated urine would point to SIADH. Correction must be controlled — no more than 8 mmol/L over 24 hours to avoid osmotic demyelination — with 4–6 hourly sodium monitoring and early endocrinology input. If sodium rises faster than intended I would stop hypertonic saline, give IV 5% dextrose and consider desmopressin to relower sodium safely.

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