Acute Water Intoxication

December 17, 2003

Bruce R. Wall, MD

Good old fashioned nephrology
(with a large dose of pulmonary)
Most nephrologists would chose to evaluate
and treat a SODIUM of 110 mEq/L rather
than a BUN of 110mg%
Be careful what you ask for you just
might get it
Lt.Col. Theodore R. Wall, USMC, Retired
Patient admitted from ER with hyponatremia
and respiratory failure no problem

Todays lecture:
Chronic polydipsia not this case
Case presentation
Laboratory review
Brief discussion of water intoxication
Pulmonary aspects @ Dr Weinmeister




Input minus output equals
accumulation
75 kg male
60% water = approx 45 Liters TBW

Intracellular Extracellular
30 L 15 L
280mosm/kg 280mosm/kg
[K+] 140mEq/l [Na+] 140mEq/l
How much water was ingested?
Initial TB solute: 280 X 45 =12,600 mosmol
Initial ECF solute: 280 X 15 = 4,200 mosmol
Initial intracellular: 12600 4200 = 8,400 mosmol

NEW TBW : 45kg + 6 kg = 51 kg
NEW TB OSM: 12,600 / 51kg = 251mosm/kg
NEW ECF volume: 4200 / 251 = 16.7kg
NEW intracellular volume: 8400 / 251 = 33.4kg


How much water?
Assume an ingestion of 6 liters:
serum osmolality of 251mosmol/kg

Estimated nadir [Na+] = osmolality / 2 =
125.5mEq

Effective Posm is approximately 2 X [Na+]
Case Presentation
21 year old AAM student at SMU
CC: can not be obtained (intubation)
History obtained from family members
Patient was asked to drink 3 - 4 gallons of water
(with hot sauce), as part of a fraternity hazing on
Friday evening
Post ingestion, patient was confused, and became
less responsive
At 4AM, patient developed a seizure, yet was not
transported to Presby ER until 7AM
Hospital day:one
Profound shock/hypotension poor
response to high dose pressor medications
Immediate respiratory failure with severe
agitation and hypoxemia; endotracheal
intubation confirmed drowning
Transfer to ICU maximal support: 100%
oxygen, maximum PEEP, IV norepinephrine
Initial SODIUM = 126mEq/L (IV @KO NS)
Case presentation: continued
Past medical history: none
Social history: 2 year football player for
Austin College. No drug or alcohol history
Mother arrived from Houston; Father
arrived from US Virgin Islands (lives in
Wash D.C.)
Medications: IV pressors, antibiotics
ROS: not available

Physical exam:
BP 100/60 on very high dose IV pressors; pulse
110 sinus tachycardia; R per vent; high pressures
Very muscular patient, intubated PO, who
eventually developed subQ crepitation from
barotrauma
HEENT: mild swelling; anicteric NECK: WNL
LUNGS: bilateral breath sounds; increased rate
COR: no murmur, increased HR
ABD: benign, although later the CT was
abnormal
Ext: no cyanosis; warm; slowly progressive edema
Neuro: unresponsive pupils; ? signs of herniation
prompted use of IV mannitol
Admit labs
WBC 17K 76%neutrophils, 6%lymphs
Hgb/Hct 13.2g%/38% Plts 380K
Urinalysis: 2+ blood, few RBCs, 360mOs/kg
Initial Serum Osm: 272, falling to 263 in
8hrs
Toxicology screen negative for tylenol, PCP,
ethylene glycol, MDMA, salicylate, ethanol,
cocaine, barbiturates, and narcotics
CXR: ? RUL pneumonia
CT Head: cerebral edema, especially in
retrospect
Additional admit labs:
Calcium 8.6mg/dl Phos 4.2g/dl
Total protein 7.6g/dl Albumin 4.8g/dl
Alk phos 63 LFTs mildly elevated
INITIAL CPK 2100
INITIAL BUN 10mg% CREAT 1.0mg%
ANION GAP 21
Therefore, working diagnosis of (+) AG
lactic acidosis from seizure, 3 hours PTA
Electrolytes day one, as serum
osmolality fell from 272 to 263
0800 1130 1320 1800 2300
Na+ 126 117 120 116 117
K+ 4.6 3.8 3.6 4.0 3.8
Cl- 89 88 90
CO2 16 19 22
AG 21 10 9 5
Creat 1.0 1.1 1.1 1.2
U osm 360 473
PO4 4.0 4.4
CPK 2100 3400 4000
Electrolytes: day 2
0300 1045 1300 1600 2000
Na+ 116 128 130 132 134
K+ 4.6 4.4
CO2 26 25
AG 6 8
Creat 1.1 1.3 1.2
PO4 1.7 2.5
CPK 6200 10,500
U osm 803 122 600
therapy DDAVP
Hospital course
Hemodynamics and oxygenation were tenuous on
day one
Patient was considered for extra-coporeal
oxygenation therapy, resulting in a transfer from 3
ICU to 4 ICU
Post transfer, his BP and PO2 IMPROVED
Abnormal CXR: bilateral infiltrates, air under R
hemidiaphragm
CT scan: larger amt of air surrounds tail of
pancreas, (L) kidney, anterior aspect of psoas
muscle, tracking down from mediastinum
Hospital course: continued
Electrolytes were normal, by hospital day 3
EEG always showed electrical activity
(patient had been severely hypoxemic, but
never required ACLS)
CNS began to improve by hospital day 4
Ventilator support was weaned by day 7
Transfer to floor day 8
Discharged home day 10
CNS damage associated with acute
hyponatremia
CPM: rare neurologic disorder reported in
malnourished/alcoholic patients
MORE COMMON brain edema, with uncal and
tonsillar herniation with diffuse cerebral
demyelination secondary to increased intracranial
pressure, with necrosis, and hypoxic brain damage
Compression of medullary respiratory center
because of brain swelling, above 5 to 8% of
baseline volume can lead to herniation -- fixed
pupils, hypoventilation, cardio instability, impaired
temperature control, pituitary and hypothalamic
infarction also possible
Water intoxication in cattle
J AFR VET ASSOC 1999 DEC; 70(4)
Water intoxication is common in cattle, and
also has been described in other domestic
animals. Comprehensive description is
lacking
Fatal water intoxication: Journal of
Clinical Pathology Oct 2003 p 803
DJ Farrell et al
64 yo woman with known MV disease
Compulsively drinking water, one evening, in
range of 30 to 40 glasses
Hours later was described as hysterical
Fell asleep, and found dead next morning
Postmortem: no tumor, bilateral pleural effusions,
LVH with large heart; increased cortisols
Na+ = 92meq/L (vitreous fluid, usually stable)
Acute delirium, seizures, coma, and death

Autopsy case of rare iatrogenic water
ingestion; Chen et al, Tongji Med Univ,
Forensic Sci International: Nov 95
21 yo female suicide attempt (powder
scraped from 18 matches)
1700 hrs: 3L of water 1730 hrs: 800ml
1800 hrs: 4L of water, via NG tube
Headache, dyspnea, cyanosis, then coma
Autopsy: cerebellar herniation, Na+ 112,
pulmonary edema, trachea and bronchial
tubes full of fluid
Literature review: Forensic Science
International (1995): continued
534 papers over 17 years only 16
fatalities
15 cases diagnosed during hospitalization
for various types of psychosis
Water intoxication is unusual in normal
people, and death is even rarer
Case report of death within 2.5 hrs is rare
Fatal child abuse by forced water
intoxication
Pediatrics 1999 JUN;103 Alan Arief,MD
3 children punished by forced intoxication
> 6 liters
Seizures, emesis, coma, hypoxemia,
average sodium 112mEq/L
Autopsy confirmed cerebral edema
Tried and convicted
Death by hyponatremia as result of
water intoxication in a
Army trainee
MIL MED 1999 MAR;164
Excessive water intake by athletes during
endurance races, to prevent heat injury has
been the recommendation
Describe a case of programmed drinking >
8 liters during initial training
One death, cerebral edema with seizure
Death by Water intoxication
MIL MED 2002 May; 167


3 deaths in recruits, usual water load of 6
to 10 liters in 2 to 3 hrs
safe limit probably 1 liter per hour
Chronic Polydipsia and
hyponatremia
Psychiatric patients, especially schizophrenia, often
have problems with water balance
6% to 8% have a history compatible with
compulsive water drinking; of these pts had
intermittent symptoms of hyponatremia
Normal patients can excrete 10 to 15 liters/d by
decreasing Uosm from 40 to 100 mosm/kg
Episodes of transient ADH release with acute
psychotic episodes
Carbamazepine and fluoxetine are associated with
SIADH
Chronic polydipsia
This is an uncommon clinical scenario, but does
not apply to our current case (which is rare)
Rx hypontremia with acute encephalopathy
rate of correction 0.5 to 1 meq/l per hr
(until a sodium of 120meq/l)
Never actively correct > 130meq/l