consci

ousnesspr
ogr
essessubst
ant
ial
l
y,punct
uat
edi
edbygener
ali
zedt
oni
c-cl
oni
csei
zur
es.
Nonconv
ulsi
vest
atusepi
l
ept
icusorapr
olongedi
ctal
stat
eaf
teracl
ust
erofgener
ali
zedt
oni
c-
cl
oni
csei
zur
esmaycompl
i
cat
ethei
nter
pret
ati
onoft
hel
evel
ofconsci
ousnest(
seeChapt
er3)
.
Pat
ient
swi
thr
api
dlydev
elopi
nghy
ponat
remi
a(t
oval
ues<110mEq/
L)becomeunr
esponsi
ve
andmaydi
spl
aypat
hol
ogi
cmot
orr
esponsesf
rom dev
elopi
ngbr
ainedema.Sei
zur
esi
n
pat
ient
swi
thhy
ponat
remi
amaysuggestahi
gherpr
obabi
l
ityofpoorout
come,
buti
nmanypa-
di
ent
s,t
heunder
lyi
ngcondi
ti
ont
hatl
edt
ohy
ponat
remi
aorcont
rol
ofbr
ainedemai
sthemai
n
det
ermi
nantofpoorout
come.Asar
ule,
sympt
omsar
emor
eli
kel
ytooccuri
fhy
ponat
remi
a
dev
elopsacut
elyt
hani
fitoccur
sov
eral
ongerper
iod.Per
ti
nentsi
gnsandsy
mpt
omsof
hy
ponat
remi
adonotoccurunt
ilpl
asmasodi
um concent
rat
ioni
s<125mmol
/L,
buti
rr
it
abi
l
ity
,
r
est
lessness,
andconf
usi
oncanoccurathi
gherl
evel
sinpat
ient
swhohav
ear
api
ddecr
easei
n
so-di
um l
evel
s.I
tshoul
dbeemphasi
zedt
hatsomepat
ient
shav
esev
eremuscl
ecr
amps.
Hy
ponat
remi
amayr
esul
tinv
erysev
eregen-er
ali
zedcr
ampsi
nli
mbsandabdomi
nal
muscl
es.
Hemi
par
esi
sfr
om hy
ponat
remi
aal
onehasbeenr
epor
tedi
nol
derl
i
ter
atur
einaf
ewcase
r
epor
ts,
wit
hcompl
eter
esol
uti
onaf
tercor
rect
ionbutwi
thoutneur
o-i
magi
ngcor
rel
ati
on.I
nthe
pastdecade,
thr
eepossi
bleneur
o-l
ogi
csy
ndr
omesassoci
atedwi
thacut
ehy
po-nat
remi
ahav
e
emer
ged,
eachwi
thspeci
fi
ccl
i
nical
feat
ures.

CENTRALPONTI
NEMYELI
NOLYSI
S

Thename"
cent
ral
pont
inemy
eli
nol
ysi
s"(
CPM)
,fi
rstcoi
nedbyAdamsandcol
-leagues,
impl
i
es
t
hatdemy
eli
nat
ioni
satt
hebaseoft
hepons,
butl
aterdescr
ipt
ionsnot
edoccasi
onal
ext
ensi
on
i
ntot
het
egment
um.
20Focal
areasofmy
eli
nol
yti
smaybeaddi
ti
onal
l
ypr
esenti
nthet
hal
amus
andput
amen.
"

Cent
ral
pont
inemy
eli
nol
ysi
sisacl
i
nical
ent
it
ythati
sfr
equent
lyl
i
nkedt
otr
eat
ment
,
par
ti
cul
arl
yrapi
dcor
rect
ionofsev
erehyponat
remi
a.Howev
er,
CPM i
sassoci
atedwi
thsev
ere
debi
l
itat
ingdi
sease,
suchassy
stemi
cadv
ancedcancerorchr
oni
cal
cohol
i
sm.I
thasal
sobeen
descr
ibedi
npat
ient
swi
thmaj
orosmol
ali
tyf
luct
uat
ions,
suchassev
erel
ybur
nedpat
ient
sand
pat
ient
swhohav
ehadl
i
vert
ranspl
ant
ati
on,
andi
npot
ient
swi
thanal
mostext
inctdi
sease,
Rey
e'ssy
ndr
ome(
aft
ermanni
tol
dier
apy
).

Thecl
i
nical
mani
fest
ati
onsofCI
M canbedi
ver
se,
butpseudobul
barpal
ay,
faci
alweal
ness,
inabi
l
ityt
oswal
l
oworspeak,
andquadr
ipl
egi
aar
epr
omi
nent3Quadr
ipl
egi
amaybemor
e
pr
onouncedi
nthear
msi
nsomepat
ient
sinot
her
s,aay
mmet
ri
esorhemi
par
esi
nisev
ident
.
Cl
i
nical
l
y,di
ff
erent
iat
ionf
rom anev
olv
ingbasi
l
arar
ter
yoccl
usi
oncanbedi
ff
icul
t,butt
he
ci
rcumst
ancesofr
ecentsodi
um cor
rect
ionshoul
dpoi
ntt
othi
sdi
sor
der
.Mor
eov
er,
thecent
ral
l
ocat
ioni
ntheponspr
ecl
udesneur
o-opht
hal
mol
ogi
csi
gnsexcepti
npat
ient
swi
thext
ensi
onof
demy
eli
nat
ionbey
ondi
tscent
ral
local
i
zat
ion.I
nthesemor
eext
ensi
vef
orms,
nyst
agmus,
abducenspal
sy,
miosi
s,andl
i
mit
ati
onofconj
ugat
eey
emov
ementi
nthehor
izont
aldi
rect
ion
ar
enot
ed.I
next
remeexam pl
es,
CPM maybemani
fest
edbyal
ocked-
insy
ndr
omewi
th,
as
expect
ed,
onl
ybl
i
nki
ngandv
ert
ical
eyemov
ement
sasameansofcommuni
cat
ion.

Cent
ral
pont
inemy
eli
nol
ysi
smaynotbemani
fest
edcl
i
nical
l
ybyneur
ologi
csy
mpt
oms
ot
hert
hanbehav
ior
alchanges,
alt
houghemot
ional
labi
l
ity
,suchascr
ying.canbel
i
nkedt
o
pseudobul
barpal
sy.Restl
essbehav
ior
,ir
ri
tabi
l
ity
,andcat
atoni
amaybet
hesol
eini
ti
al
pr
esent
ati
onofCPM

I
naddi
ti
on,
CPM char
act
eri
sti
cal
l
yhasbeendi
ff
icul
ttodi
agnoseaf
terl
i
vert
rans
pl
ant
ati
on,
414242Manypat
ient
sar
edr
owsy
,of
tenbecauseofi
ncr
easedammoni
afr
om sl
owl
y
i
mpr
ovi
nggr
aftf
unct
ion,
renal
fai
l
ure,
andot
heracut
eel
ect
rol
yteder
angement
s.I
ntheMay
o
Cl
i
nicser
ies,
thepr
eval
enceofCPM af
teror
thot
opi
cli
vert
ranspl
ant
ati
onwas1%.Al
lpat
ient
s
af
fect
edhadi
mpai
redl
evel
sofconsci
ousnessal
oneandnot
ypi
cal
pseudobul
barsi
gns.
"If
magnet
icr
esonancei
magi
ng(
MRI
)oft
hebr
aini
snotperf
ormed,
thedi
agnosi
scanbemi
ssed
andmaybecomeappar
entonl
yatpost
mor
tem exam i
nat
ionorwhenpseudobul
barpal
syand
quadr
ipar
esi
sbecomeev
identdur
ingr
eli
abi
l
itat
ionf
rom sur
ger
y

Ext
rapont
inel
esi
onsmayoccursi
mul
taneousl
ybutar
emani
fest
eddi
ff
erent
lyOnt
he
basi
sofaut
opsymat
eri
al,
iti
sest
imat
edt
hatappr
oxi
mat
ely10%ofpat
ient
swi
thCPM hav
e
ext
rapont
inel
esi
ons,
usual
l
yfoundi
nthecaudat
enucl
eus,
put
amen,
lat
eral
thal
amus,
and
l
ater
algeni
cul
atenucl
eus

Del
ayedonsetofpar
kinsoni
sm-
3weekst
o5mont
hsaf
terr
api
dcor
rect
ionofby
ponat
remi
aandsubsequentcl
i
nical
diagnosi
sofCPM-
hasbeendescr
ibed.7.
43-
47

Comput
edt
omogr
aphy(
CT)scanni
ngwi
thdet
ail
edv
iewsoft
heponsmayy
iel
dcl
ear
ly
di
sti
nct
iveabnor
mal
i
ties,
butMRIhasf
aci
l
itat
edt
hedi
agnosi
sofCPM ant
emor
tem andhas
car
eful
l
ychar
act
eri
zedt
hedi
sor
der
.Asy
mmet
ri
cal
oval
orr
oundar
eaonTl
-orT2-
wei
ght
ed
i
magesi
sfound(
FigS-
A,D)
,butl
esi
onsi
nthebaseoft
heponsmayal
sobet
ri
dentorbat
shapedbecausehor
izont
alt
ract
sar
epr
efer
ent
ial
l
yinv
olv
edandv
ert
ical
tract
sar
espar
ed(
Fig.8
-
4B,
C).

Magnet
icr
esonancei
magi
ngmayr
eveal
bil
ater
alt
hal
ami
cinv
olv
ementoft
hel
ater
aland
cent
romedi
annucl
eus,
typi
cal
inext
rapont
inemy
eli
nol
ysi
sanddi
ff
erent
iat
ingi
tfr
om t
he
bi
l
ater
alpar
amedi
ant
hal
ami
cin-f
arct
ions.I
tmaybe2weeksbef
orel
esi
onsappearonMRI
,
50

Fol
l
ow-
upMRImayshowr
esol
uti
onoft
heTIhy
poi
ntensi
ty,
presumabl
yasar
esul
tof
di
mini
shededemai
nthear
eaofdemy
eli
na-t
ion.Theext
rapont
inemani
fest
ati
onsr
e-sol
vef
ir
st.
Gr
adual
recov
eryt
ovi
rt
ual
l
ynor
-mal
neur
ologi
cfunct
ioni
spossi
ble,
eveni
npat
ient
swi
tha
l
ocked-
insy
ndr
ome.Nocor
-rel
ati
onexi
stsbet
weenper
sist
entMRIf
ind-i
ngsandsubsequent
pot
ent
ial
forr
ecov
ery
.Bul
bardy
sfunct
ionandspast
icquadr
ipar
esi
sremai
nsour
cesof
i
mpai
rmentf
ormanypa-t
ient
s.Manyoft
her
epor
tedpat
ient
sinwhom CPM dev
elopedaf
ter
l
i
vert
ranspl
an-t
ati
ondi
dpoor
ly:
"

POSTOPERATI
VEHYPONATREMI
ASYNDROMEI
NYOUNGHEALTHYWOMEN

Af
ulmi
nantneur
ologi
cdi
sor
derassoci
atedwi
thsev
ere.(
andpr
obabl
yunr
ecogni
zed)hy
ponat
remi
ahasbeenspeci
fi
cal
l
yli
nkedt
ocl
ect
ivesur
ger
y.Thecondi
ti
oni
srar
e,becausei
nthe
f
ir
stdef
ini
ngr
etr
ospect
ivesur
vey
.15womenwer
eseeni
n15medi
cal
cent
ersi
n10y
ear
s.Two
day
saf
tersur
ger
y,pat
ient
shadgener
ali
zedt
oni
c-cl
oni
csei
zur
esf
oll
owedwi
thi
n1hrby
r
espi
rat
oryar
rest
.Inmanyoft
hepat
ient
s,ser
um sodi
um l
evel
swer
enotr
out
inel
ymeasur
ed
post
oper
ati
vel
y,andt
henonspeci
fi
csi
gnsofear
lybr
ainswel
l
ing,
suchasnausea,
vomi
ti
ng,
and
headache,
wer
enotr
ecogni
zedassuch.Att
het
imeofdet
eri
orat
ionandr
esusci
tat
ion,
plasma
sodi
um v
aluesdecr
easedgr
eat
ly,
toatl
east<110mmol
/L

Manyoft
heor
igi
nal
15pat
ient
shadf
ixed,
dil
atedpupi
l
saf
terr
esusci
tat
ion;
fourpa
t
ient
sdi
ed,
andni
nepat
ient
sremai
nedi
nav
eget
ati
vest
ate.Ther
emai
ningt
opat
ient
s,who
sur
viv
edwi
thmoder
atedef
ici
ts,
hadbeent
reat
edi
mmedi
atel
yaf
tert
hef
intsei
zur
e.ACTscan
i
nthesepat
ient
smayshonebr
ainedemawi
thobl
i
ter
ati
onofsul
diandbasal
cist
erns.Aut
opsy
demonst
rat
ed"
demy
eli
nat
ioni
naddi
ti
ont
ocer
ebr
aledema.I
thasbeenassumedt
hatbr
ain
swel
l
ingmayhav
ecausedt
her
espi
rat
oryar
restf
rom.
com pr
essi
onoft
hemedul
l
athr
ough
br
ainberni
ati
on.

Ani
ntr
igui
ngf
eat
ureoft
hissy
ndr
omei
sthef
emal
epr
eponder
ance.Mostr
epor
ted
pat
ient
sar
eheal
thywomenunder
goi
ngabdomi
nal
,gy
necol
ogi
c,cosmet
ic,
orot
hermost
ly
r
elat
ivel
ymi
norel
ect
ivepr
ocedur
es.Thi
ssy
ndr
omeofphy
ponat
remi
ainwomenwi
thedema
hasbeent
ent
ati
vel
yli
nkedt
osodi
um-
pot
assi
um adenosi
net
ri
phosphat
asepumpdy
sfunct
ion,
becausesexdi
ff
erencesi
nthi
spumphav
ebeenf
oundi
nani
mal
studi
es.

Post
oper
ati
vesev
erehy
ponat
remi
awi
thr
espi
rat
oryar
resthasal
sobeendocument
edi
n
pat
ient
swi
tht
ransur
ethr
alpr
ost
atect
omy
.usual
l
yassoci
atedwi
thbl
adderi
rr
igat
ion.
Nev
ert
hel
ess,
inmanymal
epat
ient
s,t
heoutcomei
sgooddespi
tesei
zur
es.Hy
ponat
remi
acan
besev
erei
npost
-t
ransur
ethr
alpr
ost
atect
omy
,butser
um osmol
ali
tyi
squi
tehi
ghf
rom bl
adder
absor
pti
onofhy
per
ioni
cgl
yci
ne,
frequent
lyusedasani
rr
igant
.Rapi
dexcr
eti
onoft
hegl
yci
neby
t
heki
dneyr
est
orespl
asmaosmol
ali
ty,
andi
tisi
mpor
tantt
omaket
hisdi
sti
nct
ionr
athert
han
super
fici
all
yat
tr
ibut
esexdi
ff
erencest
ocompl
i
cat
ionsofhy
ponat
remi
a.

Howhy
ponat
remi
acandev
elopi
nthesepat
ient
sandnoti
nmanyot
her
sisnotent
ir
ely

cl
ear
,buti
nther
epor
tedcases,
lar
gev
olumesoff
reewat
erhadbeenadmi
nist
ered.I
naddi
ti
on,
i
nthef
ir
stpost
oper
ati
vehour
s,
manypat
ient
smayhav
esel
f-
admi
nist
eredmor
phi
nef
orpai
ncont
rol
.Repeat
eddosesof
mor
phi
nemaycausev
omi
ti
ngand,
toget
herwi
thext
ensi
vef
lui
dadmi
nist
rat
ioni
nthe
i
mmedi
atepost
oper
ati
vecour
se,
mayl
eadt
orapi
dlyev
olv
inghy
ponat
remi
a.

Ar
evi
ewofal
lpost
oper
ati
ver
espi
rat
oryandcar
diacar
rest
sinwomendur
ing1976t
o
1992i
nRochest
er,
Minnesot
a,wasnegat
ivef
orassoci
atedsev
erehy
ponat
remi
a.I
nthi
sper
iod,
1498of290,
815women(
0.5%)whohadsur
gical
procedur
esexper
iencedpostoper
ati
ve
car
diacorr
espi
rat
oryar
rest
.Innoneoft
hesepat
ient
swassev
erehy
pona-t
remi
aof<125
mmol
/Lf
ound.New-
onsetpost
oper
ati
vesei
zur
esoccur
redi
nthr
eeel
der
lypat
ient
swi
th
hy
ponat
remi
a,butal
lhadhy
ponat
remi
aassoci
atedwi
thasev
erel
i
fet
hreat
eni
ngi
l
lness.Si
nce
t
hissur
vey
,west
il
lhav
enotencount
eredanyconv
inci
ngcaseatt
heMay
oCl
i
nic.Thet
rue
pr
eval
enceoft
hisdi
sor
derneedst
obeur
therdet
er-mi
ned,
butourdat
aconv
inceust
hatt
heen
t
it
yisext
remel
yuncommon.

Av
ari
antsy
ndr
omeofcent
ral
diabet
esmel
l
itusandi
nsi
pidus,
repor
tedi
n1990,
is
cont
rov
ersi
al.Af
tersei
zur
esandr
espi
rat
oryar
rest
,decor
ti
cat
epost
uri
ngwassoonf
oll
owedby
l
ossofv
irt
ual
l
yal
lbr
ainst
em r
e-f
lexes.Whet
hert
hiscl
i
nical
syndr
omer
ep-r
esent
sanewent
it
y
or
,muchmor
eli
kel
y,si
mpl
yref
lect
ssy
stemi
cmani
fest
ati
onsi
npa-t
ient
swhobecamebr
ain
deadf
rom sev
erecer
ebr
aledemaaf
terpr
olongedr
esusci
ta-t
ionr
emai
nsunr
esol
ved.
Tr
anst
ent
ori
alher
-ni
ati
onandi
schemi
cinf
arct
sofpi
tui
tar
ylobesandt
heby
pot
hal
amuswer
e
f
oundandt
ent
ati
vel
yli
nkedt
ocl
i
nical
findi
ngsofdi
a-bet
esmel
l
itusandi
nsi
pidus,
butbot
h
t
heseabnor
mal
i
tiesal
onear
eal
socompat
ibl
ewi
thbr
aindeat
horwi
thbr
ain-
swel
l
ing-
induced
compr
essi
onoft
hedi
encephal
onagai
nstt
hecl
i
vus,
resul
ti
ngi
nhy
pot
hal
ami
cinf
arct
sor
sev
eri
ngoft
hepi
tui
tar
yst
alk.

Conf
ir
mat
ionoft
hiscont
rov
ersi
alf
indi
ngofy
oungf
emal
esuscept
ibi
l
ityt
oacut
eos
mot
icst
resswasal
sosoughti
nani
mal
exper
iment
s.I
nit
ial
clai
msi
nratst
udi
esbyAr
iefand
i
nvest
igat
orst
hatseemedt
osuppor
taf
emal
epr
ocl
i
vit
ytohy
ponat
remi
ainducedbr
aini
njur
y
wer
enotconf
ir
medi
nasubsequentst
udy
.Br
ainadapt
ati
ont
oacut
eby
ponat
remi
ain
pr
epubescentr
atswassi
mil
art
othati
nol
derr
ats.
38.
38

OSMOTI
CDEMYELI
NATI
ONSYNDROME

Al
thoughdi
rect
lyr
elat
edt
othecor
rect
ionofhy
ponat
remi
a,t
hiswel
l
-descr
ibedcl
i
nical
phenomenonr
emai
nsaneni
gma.I
nthei
rrepor
tonei
ghtpat
ient
str
eat
edov
erat5-
yearper
iod
att
woi
nst
it
uti
ons,
Ster
nsandassoci
atespost
ulat
edt
hatmy
eli
nol
yti
clesi
onsi
nthedeep
cor
ti
cal
cel
ll
ayer
sandi
ntheponsr
esul
tfr
om l
atr
ogeni
crapi
dcorr
ect
ionofhy
ponat
remi
a.
Possi
bleet
iol
ogi
cconsi
der
ati
onsar
ethe"
gri
d"phenomenon,
suggest
ingst
rangul
ati
onof
my
eli
nat
edf
iber
sbysur
roundi
ngedemai
nthepons,
and"
osmot
icendot
hel
i
ali
njur
y,"whi
chi
m
pl
i
est
hatr
api
dosmot
icchangesofendot
hel
i
alcel
l
sint
hegr
aymat
termayr
eleasemy
elot
oxi
c
f
act
ors.

A1991exper
iment
alst
udy
,howev
er,
off
eredanov
elhy
pot
hesi
sbasedont
hef
indi
ng
t
hatl
ostosmol
esar
enotr
api
dlyr
epl
acedwhenneeded.Lossofosmol
esi
nhy
ponat
remi
a
t
reat
edwi
thr
api
dinf
usi
onofhy
pert
oni
csal
i
nei
sof
fsetnotbyanaccumul
ati
onofosmol
esi
n
t
hebr
ainbutbyel
ect
rol
yter
eaccumul
ati
onandasaconsequenceamuchsl
oweri
ncr
easei
n
osmol
es.Theabsenceofosmol
epr
otect
ionandi
ncr
easedhi
ghi
oni
cst
rengt
hmaybehar
mful
t
opr
otei
nint
eract
ionsi
nol
i
godendr
ocy
tes.Whet
hert
hisexpl
anat
ioni
ssuf
fi
cientt
oexpl
ain
t
hissy
ndr
omehasnoty
etbeenunar
guabl
yshown.

Thecl
i
nical
feat
uresoft
hissy
ndr
omet
endt
obest
ereot
ypi
cal
.Af
tercor
rect
ionofsev
ere
hy
ponat
remi
awi
thhy
per
toni
csal
i
ne,
pat
ient
sawakewi
thoutanymaj
orappr
eci
abl
edef
ici
tonl
y
t
ohav
egr
adual
det
eri
orat
ion2t
o3day
slat
er.Af
terr
api
dcor
rect
ionofser
um sodi
um
def
ici
ency
,pat
ient
ssi
gni
ficant
lyi
mpr
ovei
nlev
elofconsci
ousnessbutcont
inuet
ocompl
ainof
t
hrobbi
ngheadachesandnausea.New-
onsetv
omi
ti
ngandsei
zur
esmar
kthebegi
nni
ngofa
l
apsei
ntoanunr
esponsi
vecoma,
occasi
onal
l
ywi
thaf
atal
cour
se.Somecl
i
nical
feat
ures(
but
nott
hepat
hol
ogi
cfi
ndi
ngs)mayber
emi
niscentofdel
ayedpost
resusci
tat
ionencephal
opat
hy,
asr
epor
tedbyPl
um andco-
wor
ker
s(seeChapt
er7)
.

Pat
hol
ogi
cdat
afort
hesepat
ient
sar
escar
ce,
butonecar
eful
l
ydocument
edcaser
epor
t
not
edmul
ti
focal
demy
eli
nat
ionwi
thoutanyev
idenceofmassi
vebr
ainedema.Thi
srar
e
sy
ndr
omemaybeconsi
der
edav
ari
antofCPM andt
husmayoccurl
essf
requent
lyi
f
hy
ponat
remi
aispr
udent
lymanaged.

TREATMENTOFACUTESEVEREHYPONATREMI
A

Manygui
del
i
nesf
ori
nter
vent
ioni
nacut
ehyponat
remi
aluav
ebeenpr
oposed,
butt
ri
alsi
n
humansubj
ect
sar
elacki
ng.Reader
sar
eref
err
edt
omanyexcel
l
entr
evi
ewsont
hissubj
ect720
-
7

Thecl
i
nical
dil
emma,
ift
heconceptofAr
iel
li
saccept
ed,
ist
hatacut
esev
erehy
ponat
remi
amay
,inpr
edi
sposedpat
ient
s,beassoci
atedwi
thsev
erebr
ainedemar
esul
ti
ngi
n
i
rr
ever
sibl
eher
niat
ion.Ont
heot
herhand,
rapi
dcor
rect
ion(
>24mmol
/Laday
)mayr
esul
tinCPM
orosmot
icdemy
eli
nat
ionsy
ndr
ome.Mostexper
tsr
efut
erapi
dcor
rect
ionmet
hodsandai
m at
agr
adual
incr
easei
npl
asmasodi
um.

Tr
eat
mentofacut
esev
erehy
ponat
remi
ashoul
ddependonwhet
hersy
mpt
omsar
e
pr
esent
.Int
hev
astmaj
ori
tyofpat
ient
s,f
lui
dov
erl
oadcauseshy
ponat
remi
a,butot
hert
ri
gger
s
shoul
dbei
dent
if
iedandcor
rect
ed.I
tmaybepr
udentt
oincr
easet
heser
um sodi
um
concent
rat
iont
oval
uesof125mmol
/Lwi
th3%hy
per
toni
esal
i
ne.Addi
ti
onal
fur
osemi
deorany
ot
herl
oopdi
uret
icmaybeappr
opr
iat
etodecr
easeex
cessf
reewat
er,
butt
hei
nit
ial
diur
eti
c
r
esponsemaybeunpr
edi
ctabl
eandmayl
eadt
ounexpect
edhi
ghersodi
um v
alues.

Tr
eat
mentofsy
mpt
omat
ichy
ponat
remi
aitt
ypi
cal
l
ybegunwi
th3%hy
per
toni
csal
i
ne.
Knowl
edgeoft
het
reat
mentpr
otocol
isi
m por
tantf
ort
heconsul
ti
ngneur
ologi
sti
njudgi
ng,
in
anyonepat
ient
,thepossi
bler
iskofCPM (
Tabl
e8-
7).Usi
ngt
hef
ormul
aby
.Andr
oguéand
Madi
asi
nTabl
e8-
7maybehel
pful
.Forexampl
e,t
hecor
rect
ioni
naf
emal
epat
ient(
body
wei
ght601g)wi
thahypot
oni
chy
ponat
remi
aof100mmol
/L,
wit
huseof3%hy
per
toni
csal
i
ne,
i
s513100/
0.5x60x115.
5mmol
/L.Thus,
1Lof3%hy
per
toni
csal
i
ne(
assumi
ngacl
osed
sy
stem andnosubst
ant
ial
addi
ti
onal
renal
lossesbymanni
tol
orf
urosemi
de)wi
l
lincr
easet
he
ser
um sodi
um concent
rat
ionwi
th15.
3mmol
/LThei
nfusi
onr
atedependsont
hepr
esenceof
sy
mpt
oms(
brai
nedema)butsodi
um i
ncr
easeshoul
dremai
nwi
thi
n1mmol
/Lperhour
.Thus,
ani
ncr
easeby
3mmol
/Lov
er3hrwoul
drequi
re3/
13.
3.or0.
23,
li
terofhy
per
toni
csal
i
neor230/
3,or77mL
perhour
."Whenhy
ponat
remi
ahasbeencor
rect
edt
oappr
oxi
mat
ely130mmol
,thepat
ientcan
bet
reat
edwi
thf
lui
drest
ri
cti
ononl
yandi
nfusi
oncanbe,
discont
inued.Pl
asmasodi
um
concent
rat
ionshoul
dbecheckedev
eryhourt
opr
eventr
api
dcorr
ect
ionand,
mor
eimpor
tant
,
"
over
cor
rect
ion"t
oval
uesabov
e140mEq/
LPat
ient
swhodonothav
eimpr
ovementandwho
cont
inuet
ohav
esei
zur
esshoul
dbegi
venapheny
toi
nloadr
athert
hanar
api
dincr
easei
nthe
r
ateofsodi
um admi
nist
rat
ion.Anot
herappr
oachi
suseofv
asopr
essi
nant
agoni
sts,
and
pr
eli
minar
yexper
ienceshowsar
api
dcor
rect
ionofhy
ponat
remi
a.Thi
str
eatmentshoul
dnotbe
usedunt
ili
tssaf
etyhasbeendemonst
rat
ed,

Pat
ient
smaybenef
itf
rom ashor
tcour
seofdexamet
hasone(
forexampl
e,4mggi
ven
f
ourt
imesaday
)whensodi
um cor
rect
ioni
sunexpect
edl
yrapi
d.Dat
ainr
atssuggestt
hat
demy
eli
nat
ioncanbepr
event
edwi
thhi
ghdosesofcor
ti
cost
eroi
ds.
74

Acut
epar
kinsoni
sm f
rom CPM r
espondst
olev
odopasubst
it
uti
on.Gener
ali
zeddy
stoni
a
orpr
edomi
nantor
oli
ngual
dyst
oni
aandat
het
osi
smayr
espondt
otr
ihexy
pheni
dyl
(maxi
mum of
40mg/
day
)ort
iapr
ide(
maxi
mum of900mg/
day
).Excel
l
entr
esponsewi
thr
ecov
eryt
othe
poi
ntofi
ndependentl
i
fewasanecdot
all
yrepor
tedi
napat
ientt
reat
edwi
tht
hyr
otr
opi
n-
r
eleasi
nghor
monei
nject
ionsaf
terpl
asmaexchange(
5to14exchanges)
,butspont
aneousr
e
cov
eryf
rom CPM i
swel
lknown.
Hy
per
nat
remi
a

Pat
ient
sar
esuscept
ibl
etohy
per
mat
remi
awhent
her
eisnoaccesst
owat
er,
16.
77Noaccess
t
owat
eri
scount
eredbyr
enal
concent
rat
ingmechani
smsandi
sfol
l
owedbyasensat
ionof
t
hir
st.Hy
per
nat
remi
aisusual
l
yther
esul
tofwat
erdepl
eti
oni
nexcessofsodi
um,
but
hy
per
nat
remi
acanoccuri
nst
atesofeuv
olemi
aorhy
per
vol
emi
a.Commoncausesofi
ncr
eased

t
otal
bodysodi
um ar
eexcessadmi
nist
rat
ionofhy
per
toni
csodi
um bi
carbonat
etocor
rect
met
abol
i
caci
dosi
s,mal
funct
ionoft
hedi
aly
sat
e-pr
opor
ti
oni
ngsy
stem dur
inghemodi
aly
sis,
andseawat
erdr
owni
ng

Anot
hercommoncausei
ssust
ainedi
nfusi
onofl
argev
olumesofi
sot
oni
csodi
um
chl
ori
dei
npat
ient
swi
thhy
pot
oni
cfl
uidl
ossorshock.Themostf
requent
lyencount
eredcauses
ofhy
per
nat
remi
aint
heI
CUar
eli
stedi
nTabl
e8-
8.Fai
l
uret
orepl
acei
nsensi
blel
ossesf
rom t
he
ski
nandr
espi
rat
oryt
racti
sthemostcommoncauseofhy
per
mat
remi
ainI
CUs.

CLI
NICALFEATURES

Af
airdegr
eeofconcor
danceexi
stsbet
weent
hecl
i
nical
mani
fest
ati
onsofhy
per
nat
remi
aand
t
heext
racel
l
ularf
lui
ddef
ici
t.Al
thoughhy
per
nat
remi
ahasi
tsgr
eat
estef
fectont
hecent
ral
ner
voussy
stemi
,ot
herf
eat
uresi
m medi
atel
ysuggestahy
per
osmol
arst
ate.Si
gnsof
ext
racel
l
ularv
olumedepl
eti
onar
edehy
drat
ion,
ski
ntent
ing,
drymucousmem br
anes,
and
t
achy
car
dia.Thesesi
gnsar
elessobv
iousi
nel
der
lypat
ient
s.Mostpat
ient
sar
edr
owsy
,but
per
iodsofdi
mini
shedar
ousabi
l
itymaybei
nter
sper
sedwi
thper
iodsofr
est
lessnessand
conf
usi
on.I
nmanyel
der
lypat
ient
s,ami
l
ddegr
eeofAl
zhei
mer
'sdi
scaseorv
ascul
ardement
ia
maybeunmaskedoraggr
avat
edbyhy
per
naur
emi
a.Focal
mot
orsi
gnsdonotoccur
,andi
l
pr
esentast
rokewi
thdehy
drat
ioni
samor
eli
kel
yexpl
anat
iont
hant
heconv
erse.Gener
ali
zed
t
oni
c-cl
oni
csei
zur
esar
eunusual
,ev
eni
npat
ient
swi
thmar
kedi
ncr
easei
nsodi
um l
evel
s(>160
mmol
/L)
.Ast
eri
xi
sandmy
ocl
onushav
ebeendescr
ibedbutar
egenerál
l
yseeni
npat
ient
swho
al
sohav
ehepat
icencephal
opat
hy.Ot
herv
eryi
nfr
equentcl
i
nical
mani
fest
ati
onsar
eri
gidi
ty,
t
remor
,myocl
onus,
andchor
ea.

Asdehy
drat
ionandhy
per
nat
remi
abecomesev
ere,
pat
ient
sbecomeunr
esponsi
ve.Thecl
i
nical
cour
semaybef
ulmi
nanti
npost
oper
ati
vepat
ient
sorpat
ient
sinwhom hemodi
aly
sisi
s
associ
atedwi
tht
echni
cal
probl
ems.

Ar
ief
fandCar
rol
l
'sst
udyonhy
pergl
ycemi
aandhy
per
mat
remi
ashowedt
hatmostpat
ient
s
r
emai
nedal
ertwhenpl
asmaosmol
ali
tyr
emai
nedunder350mosm/
kg.Pr
ogr
essi
vedr
owsi
ness
occur
redbey
ondt
hiscr
it
ical
val
ue.Usual
l
y,howev
er,
ther
eisamar
kedov
erl
apbet
weent
he
degr
eeofhyper
nat
remi
aandt
hedegr
eeofcoma.

Hy
per
nat
remi
amaynotsi
gni
fi
cant
lyi
ncr
easet
hepr
obabi
l
ityofneur
ologi
csequel
ae.Al
though
per
manentcogni
ti
vechanges,
att
ent
ional
def
ici
ts,
andpoormemor
yar
ecommoni
npat
ient
s
whosur
viv
esev
erehyper
nat
remi
a,t
heunder
lyi
ngcl
i
nical
condi
tiont
rul
ydet
ermi
nesout
come
andmor
bidi
ty,
8051Mor
tal
i
tyf
rom sev
erehy
per
nat
remi
a(>160mmol
/L)canbe70%i
n
suscept
ibl
epat
ient
s.Recov
eryi
npat
ient
swhor
emai
nal
ertatpeaksodi
um v
aluesi
scommon.

TREATMENT

Thei
deal
rat
eoff
lui
dresusci
tat
ioni
nhyper
nat
remi
cpat
ient
sisnotknownbutmaydependi
n
par
tont
her
ateatwhi
chhy
pernat
remi
adev
elops.Fat
alcer
ebr
aledema,
oft
enaccompani
edby
gr
andmal
sei
zur
es,
occur
redi
npat
ient
swi
thi
n24hraf
teracut
ehy
per
nat
remi
ahadbeen
cor
rect
ed.Asi
nhyponat
remi
a,ov
erl
yrapi
dcor
rect
ionmaybehazar
dous,
butcl
i
nical
evi
dence
i
slacki
ng.I
nhy
pov
olemi
cpat
ient
s,i
ntr
avascul
arv
olumeshoul
dber
epl
acedwi
thi
sot
oni
c
sal
i
neorcol
l
oids,
andar
educt
ionof1t
o2mEq/
Lofsodi
um perhourmaybepr
udent
.Hy
per
nat
remi
amayr
eoccuri
ftheunder
lyi
ngsy
stemi
cdi
seasei
snotcor
rect
edandadmi
nist
rat
ion
oft
ri
gger
ingdr
ugsi
snotdi
scont
inued.

Hy
pokal
emi
a

Mostcr
it
ical
l
yil
lpat
ient
sseem t
ohav
ehy
pokal
emi
aatsomest
agei
nthei
rcl
i
nical
cour
se,
and
of
tent
her
eismor
ethanoner
easonf
orpot
assi
um def
ici
ency
.Commoncausesf
or
hy
pokal
emi
aar
egast
roi
ntest
inal
orf
rom ski
nlossesordr
ugs(
Tabl
e8-
9).Nasogast
ri
c
suct
ioni
ngcancauseext
racel
l
ularf
lui
dvol
umedef
ici
tst
hatr
esul
tini
ncr
easedser
um
concent
rat
ionofal
dost
erone,
whi
chi
ntur
nresul
tsi
nincr
easedr
enal
excr
eti
onofpot
assi
um
andt
hushy
pokal
emi
a.Thedev
elopmentofmet
abol
i
cal
kal
osi
sfr
om nasogast
ri
csuct
ioni
ng
mayal
socauseani
ncr
easei
nrenal
pot
assi
um excr
eti
on.Muscl
eweaknessi
stheonl
y
neur
ologi
cmani
fest
ati
oni
npr
ofoundhy
pokal
emi
a.

MYOPATHY

Pot
assi
um l
ossr
educesexci
tabl
eti
ssuesuchasmuscl
ebyi
ncr
easi
ngt
het
hreshol
dfori
ni
t
iat
ionoft
heact
ionpot
ent
ial
;depl
eti
onofgl
ycogenst
oresorr
habdomy
oly
sismaybet
hemai
n
causeofmuscl
eweakness.Pot
assi
um depl
eti
onf
rom anycausemayl
eadt
o
sev
eremuscl
eweaknessand,
ini
tsext
remef
orm,
toquadr
ipl
egi
aandr
espi
rat
oryf
ail
ure.
Neur
ologi
cmani
fest
ati
onsar
einev
itabl
ewi
thpl
asmapot
assi
um concent
rat
ionsof<2mEq/
L,
butmanypat
ient
swi
thpot
assi
um l
ossesr
emai
nsy
mpt
om-
fr
ee.Whent
heser
um pot
assi
um
l
evel
decr
eases(
<3mEq/
L),
tot
albodypot
assi
um st
oresmostl
i
kel
yar
esi
gni
fi
cant
lydepl
eted
andel
ect
rocar
diogr
aphi
cchangesof
tenseen.Pr
omi
nentUwav
es,
STsegmentchanges,
dampenedTwav
e,and,
mor
eim por
tant
,at
ri
alandv
ent
ri
cul
arar
rhy
thmi
asar
ety
pical
findi
ngs.

Muscl
eweaknessusual
l
ypr
ogr
essesov
ersev
eral
day
sint
heI
CU.Pr
oxi
mal
leg,
neck,
andt
runkmuscl
eweaknessi
sanear
lysi
gn.Manypat
ient
scannotsi
twi
thouthel
porl
i
ftt
hei
r
headf
rom t
hepi
l
low.Achi
ngpai
nint
hebackandl
argerpr
oxi
mal
fleshymuscl
esi
scommon.
Muscl
ecr
amps,
noct
urnal
my.ocl
onus,
andsy
mpt
omsmi
micki
ngr
est
lessl
egsy
ndr
omemay
becomeext
remel
ydi
srupt
iveatni
ghtandr
esul
tinaddi
ti
onal
fat
igueandexhaust
ion.I
n
except
ional
cases,
hypokal
emi
amaybeassoci
atedwi
thr
api
dlyascendi
ngweaknessand
r
espi
rat
oryf
ail
uresuggest
ingGui
l
lai
n-Bar
résy
ndr
ome,
buthal
l
mar
ksoft
hisdi
sor
der
,suchas
ungl
i
ng.ar
efl
exi
a,andcr
ani
alner
vedef
ici
ts,
areabsent
.Di
stal
muscl
essel
dom becomepr
omi
nent
lyi
nvol
ved,
buti
ftheydo,
theyr
ecov
erf
ir
staf
tercor
rect
ionofhy
pokal
emi
a.Vent
ilat
ory
f
ail
ure,
dif
fi
cul
tyswal
l
owi
ngsecr
eti
ons,
andal
urr
edspeechhav
ebeendescr
ibed,
butas
ment
ionedpr
evi
ousl
y,usual
l
ytheel
ect
rocar
diogr
aphi
cabnor
mal
i
tiesandpr
ogr
essi
veweakness
hav
eal
readypr
ompt
edr
api
dcor
rect
ion.

Mostpat
ient
swi
thsev
erehy
pokal
emi
ahav
eami
l
ddegr
eeofr
habdomy
oly
sis.The
mechani
sm ofr
habdomy
oly
sisi
nsev
erehy
pokal
emi
aisnotknown.Rhabdomy
oly
sis(
see
Chapt
er4)i
snotsi
gni
fi
cantenought
oresul
tini
tscl
assi
cmani
fest
ati
onswi
thcom par
tment
sy
ndr
omesoracut
etubul
arnecr
osi
s.Wi
despr
eadmuscl
epai
nthatmayhav
est
art
edi
nthe
cal
vesi
spr
esent
.Muscl
esar
efi
rml
yswol
l
enandext
remel
ytendert
otouch.Manypat
ient
s
compl
ainofi
ntensi
fyi
ngpai
nwi
thmov
ement
.Cr
eat
ineki
nasel
evel
sar
eincr
eased,
butmar
ked
sur
gei
nval
uemaybeshor
tandt
husmi
ssedi
nar
andom sampl
e.Muscl
ebi
opsi
esi
naf
ew
r
epor
tedcaseshav
enotl
edt
onewi
nsi
ghti
ntot
hepat
hol
ogi
cmechani
sms.Thespeci
mens
showv
acuol
i
zat
ionofTt
ubul
es,
nonspeci
fi
cnecr
osi
s,t
ypeI
Ifi
berat
rophy
,andphagocyt
osi
s
andr
egener
ati
onCor
rect
ionofhy
pokal
emi
aresul
tsi
nmar
kedi
mpr
ovementi
naf
ewweeks,
as
i
tdoesi
npat
ient
swi
thabnormal
muscl
ebi
opsyf
indi
ngs.

TREATMENT
Cor
rect
ioni
npat
ient
swi
thsev
erehy
pokal
emi
aisusual
l
yatamaxi
mum r
ateof10t
o20
mEq/
hr.Ani
nfusi
onr
ateexceedi
ng201mEq/
hrmayr
esul
tinpot
ent
ial
l
yli
fe-
thr
eateni
nghear
t
bl
ockandshoul
dingener
albeav
oided,
incl
udi
ngi
npat
ient
swi
thsev
eremuscl
epai
n.Pat
ient
s
mayhav
ear
elapseofpr
oxi
mal
weaknessaf
terpot
assi
um cor
rect
ion,
usual
l
yfr
om r
api
dent
ry
ofpot
assi
um i
ntodepl
etedcel
l
s.Ther
efor
e,t
hepot
assi
um cor
rect
ionshoul
dbecont
inuedunt
il
mostoft
heweaknesshasr
esol
ved.Per
manentweaknesshasnotbeendescr
ibedaf
ter
i
ntr
avenouscor
rect
ionofpot
assi
um concent
rat
ion.

Hy
per
kal
emi
a

I
ncr
easedpl
asmapot
assi
um l
evel
smayal
tert
heel
ect
ri
cal
exci
tabi
l
ityofner
veandmuscl
e
membr
anes,
usual
l
ywhent
heconcent
rat
ionr
eaches7mEq/
LMuscl
eweaknesshasbeen
expl
ainedbypot
assi
um-
tr
igger
edsust
aineddepol
ari
zat
ion.Thi
sst
ater
esul
tsi
nsodi
um channel
i
nact
ivat
ion,
anddespi
tei
ntactsy
napt
ict
ransmi
ssi
on,
themot
orendpl
ateandmuscl
ecel
l
membr
aner
emai
ninexci
tabl
e.

Hy
per
kal
emi
aiscommoni
nmedi
cal
ICUsbecauseadi
spr
opor
ti
onat
elyl
argenumberof
t
hepat
ient
shav
erenal
fai
l
ure.

Hy
per
kal
emi
ahasal
sobeenanecdot
all
ydescr
ibedi
npat
ient
soncar
diacby
pass.I
n
t
hesepat
ient
s,i
ncr
easedpl
asmapot
assi
um maybei
nducedbywashoutofi
schemi
cun
der
per
fusedar
easdur
ingt
hebody
'sby
passper
iodormaybecausedbyr
ewar
mingaf
ter
hy
pot
her
mia.Mostcommonl
y,hy
perkal
emi
aisencount
eredpat
ient
swi
thr
enal
oradr
enal
f
ail
ure.Hy
poadr
enal
i
sm i
sthemostcommonadr
enal
disor
derr
esul
ti
ngi
n
hy
per
kal
emi
a,i
spot
ent
ial
l
yli
fet
hreat
eni
ng.andcanbeov
erl
ookedf
orsomet
imei
ntheI
CU.
Cer
tai
ndr
ugs,
oft
ent
hoset
hati
mpai
rrenal
funct
ion,
mayi
ncr
easepot
assi
um l
evel
s(Tabl
e8-
10)
.

Ot
hercausesar
epseudohy
per
kal
emi
afr
om hemol
ysi
sdur
ingv
eni
punct
ure.
pseudohy
per
kal
emi
aassoci
atedwi
thsev
eret
hrombocy
tosi
sorl
eukocy
tosi
s,andhy
per
kal
emi
a
associ
atedwi
thsucci
nyl
chol
i
neuse.

CLI
NICALFEATURES

Thepat
hophy
siol
ogi
cconsequencesofhyper
kal
emi
a(pot
assi
um concent
rat
ions>7.
5mEq/
L)
ar
epr
edomi
nant
lycar
diac.Car
diacconduct
ionabnor
mal
i
tiescanl
eadt
owi
deni
ngoft
hePR
i
nter
val
andQRScompl
ex,
buti
nit
ial
changesar
eapeaki
ng,
nar
rowedTwav
eandashor
tened
QTi
nter
val
.Vent
ri
cul
arf
ibr
il
lat
ionmayoccur
.

Ther
elat
ionshi
pbet
weenhy
per
kal
emi
aandcar
diacmani
fest
ati
onsi
snotal
way
scl
ear
,
par
ti
cul
arl
ywhent
hei
ncr
easei
npot
assi
um concent
rat
ioni
sgr
adual
.Neur
ologi
c
mani
fest
ati
onsmaypr
ecedecar
diacmani
fest
ati
onsNeur
ologi
cmani
fest
ati
onsmaybecome
mor
eev
identt
hancar
diacmani
fest
ati
onsi
npat
ient
swhohav
ehy
per
cal
cemi
a,whi
chmay
pr
otectt
hehear
tfr
om dy
srhy
thmi
asSi
mil
art
ohy
pokal
emi
a,hy
per
kal
emi
amayr
esul
tin
pr
oxi
mal
legweaknesswi
thi
nabi
l
ityt
oli
ftt
hel
egsf
rom t
hebed.
-50Percussi
onmy
otoni
acan
bedemonst
rat
edi
nsomepat
ient
s.Bur
ningdy
sest
hesi
aswi
thoutobj
ect
ivesensor
ylossar
e
v
erycommon,
alsosuggest
ingper
ipher
alner
vei
nvol
vementr
athert
hanpr
imar
ymuscul
ar
di
sease.Whenhy
per
kal
emi
aisnotappr
eci
ated,
thecondi
tionmaywor
sent
oquadr
ipl
egi
aand
r
espi
rat
oryf
ail
ure.Tr
ansi
entdi
plopi
ahasbeenascr
ibedt
omy
otoni
aint
hei
nter
nal
andex
t
ernal
ocul
armuscl
es.Faci
alandphar
yngeal
muscl
esmaybeaf
fect
ed;
other
wise,
crani
alner
ve
def
ici
tsar
euncommon.Somepat
ient
smayhav
egener
ali
zedmy
otoni
aint
hef
orear
ms,
hands,
andcal
ves.

TREATMENTANDOUTCOME

I
nli
fe-
thr
eat
eni
nghy
per
kal
emi
a,ef
for
tsshoul
dbedi
rect
edatal
ll
evel
s-t
hati
s,st
abi
l
izat
ionof
t
hehear
twi
thcal
cium car
bonat
e,i
ncr
easi
ngpot
assi
um i
nfl
uxwi
thandgl
ucoseorbi
car
bonat
e,
andel
i
minat
ionoft
otal
bodypot
assi
um st
oreswi
thcat
ionexchanger
esi
nsordi
aly
sisi
f
necessar
y.I
nlesscr
it
ical
sit
uat
ions,
eff
ort
sshoul
dbedi
rect
edatcor
rect
ingt
heunder
lyi
ng
cause,
eli
minat
ingpot
assi
um sour
ces,
andi
ncr
easi
ngpot
assi
um excr
eti
on(
forexampl
e,by
cat
ion-
exchanger
esi
ns,
diur
eti
cs,
ordi
alysi
s).Al
lpat
ient
srecov
erf
rom weaknesswi
thi
n1t
o4
hraf
tert
reat
ment
;lackofr
ecov
erysuggest
sot
hercauses.

Hy
pophosphat
emi
a

Thet
ruei
nci
denceofsev
erephosphor
usdepl
eti
oni
ntheI
CUi
snotknown,
butt
hispat
ient
popul
ati
oni
scer
tai
nlypr
edi
sposed.Cr
it
ical
l
yil
lpat
ient
shav
eani
ncr
easedneed.ofphosphat
e.
Mosti
nst
ancesofdepl
eti
onar
eassoci
atedwi
thl
ong-
ter
m ant
aci
dtherapy
,hemodi
aly
sis,
hy
per
ali
ment
ati
onwi
thphosphat
e-poorsol
uti
ons,
andsepsi
s-91(
Tabl
e8-
11)
.In10%t
o20%of
pat
ient
s,t
hecauseofhy
pophosphat
emi
aisunknown.I
npat
ient
swi
thsev
erebur
ns,
prof
ound
hypophosphat
emi
aof
tenoccur
sint
her
ecover
yphase,
presumabl
yfr
om i
ncr
easedanabol
i
sm
dur
ingheal
i
ng.Mi
l
dasy
mpt
omat
ichy
pophosphat
emi
amayoccuri
npat
ientwi
thr
espi
rat
ory
al
l
alosi
sei
therf
rom mechani
cal
vent
il
ati
onwi
thr
elat
ivel
ylar
get
idal
vol
umesorf
rom
spont
aneoushy
per
vent
il
ati
on.I
not
herpat
ient
s,hy
pophosphat
emi
a

maybecomemor
epr
ofoundaf
tergl
ucosei
nfusi
on,
par
ti
cul
arl
yint
hosewhoar
est
arv
edand
emaci
ated.

Theneur
ologi
cmani
fest
ati
ons-
canber
eal
ist
ical
l
yexpect
edonl
ywhenser
um
phosphat
elev
elsar
ebel
ow1mg/
dL.
92Forsei
zur
esandpr
ofoundneur
omuscul
ar
mani
fest
ati
onst
ooccur
,asubst
ant
ial
decr
easebel
ow0.
5mg/
dLmustt
akepl
ace.
9⁹2
ACUTEFLACCI
DAREFLEXI
CPARALYSI
S

Asal
i
entf
eat
ureoft
hisgener
all
yuncom moncondi
ti
oni
sit
srapi
donsetandpr
ogr
essi
on.
Usual
l
ywi
thi
n1day
,per
ior
alpar
est
hesi
asar
efol
l
owedbyv
irt
ual
l
ycompl
etequadr
ipl
egi
a,
pt
osi
s,anddi
ff
icul
tyswal
l
owi
ng.Sensor
yat
axi
amayoccur
.Thi
sdr
amat
icpr
ogr
essi
onof
sy
mpt
omsi
ssel
dom seeni
nICUSst
aff
edbyphy
sici
ansawar
eoft
hedanger
sofsubopt
imal
suppl
ement
ati
onofphosphat
eint
hesepat
ient
s.

Apr
obabl
ymuchmor
ecommonmani
fest
ati
onofsev
erehy
pophosphat
emi
aisdi
a
phr
agmat
icweaknessassoci
atedwi
thpr
oxi
mal
muscl
eweakness.95-
97Di
aphr
agmat
icf
ail
ure
associ
atedwi
thhy
pophosphat
emi
aresul
tsi
nani
nabi
l
ityt
obeweanedf
rom t
hev
ent
il
ator
.In
pat
ient
swi
thchr
oni
cpul
monar
ydi
seaseandanymedi
cal
orsur
gical
cri
ti
cal
il
lness,
hy
pophosphat
emi
amaymar
kedl
ycont
ri
but
etot
heal
readyhi
ghpr
opensi
tyf
orweani
ngf
ail
ure.
Phosphor
ushasbeenshownt
oimpr
ovei
nspi
rat
orypr
essur
esandt
her
efor
emayopt
imi
zet
he
cl
i
nical
condi
ti
onsf
orweani
ngf
rom t
hev
ent
il
ator
.

HYPOPHOSPHATEMI
CENCEPHALOPATHY

Ani
ncompl
etel
ydel
i
neat
edencephal
opat
hyassoci
atedwi
thphosphor
usdepl
eti
onhasbeen
descr
ibed.
3.94Sev
erehy
pophosphat
emi
amaybeassoci
atedwi
thcombat
ivebehav
ior
,acut
e
conf
usi
onal
stat
e,sei
zur
es,
andcoma.Tr
emor
,at
axi
a,ny
stagmus,
andbi
l
ater
alabducens
par
esi
shav
ebeennot
ed.cl
osel
ymi
micki
ngWer
nicke'
sencephal
opat
hy.Manyot
hercl
i
nical
mani
fest
ati
onshav
ebeenr
epor
ted,
incl
udi
ngast
eri
xi
s,t
remor
s,at
axi
a,andpseudobul
barpal
sy,
butmanyoft
hesel
api
dar
ydescr
ipt
ionshav
enotbeenconf
ir
medbyneur
ologi
sts.I
naddi
ti
on,
changesi
nlev
elofconsci
ousnessi
ntheseunusual
casesr
epor
tedi
nthel
i
ter
atur
ear
emor
e
l
i
kel
ytobeassoci
atedwi
thmar
kedhypoxi
afr
om al
veol
arhy
pov
ent
il
ati
oncausedby
di
aphr
agmat
icweakness.

TREATMENT

I
nthev
astmaj
ori
tyoft
hepat
ient
s,or
alphosphat
esuppl
ement
ati
oni
spr
efer
redandcanbe
easi
l
yachi
evedbyi
ncr
easi
ngmi
l
kpr
oduct
sint
hedi
etorbyaddi
ngst
andar
dor
alpr
epar
ati
ons.
I
nsev
erecases,
int
rav
enousphosphat
esuppl
ement
ati
onatadoseof2mg/
kgev
ery6hri
s
appr
opr
iat
e.98.
99Theneur
ologi
cfi
ndi
ngscompl
etel
yresol
vewhent
heser
um phosphat
e
concent
rat
ionr
etur
nst
oval
uesabov
e1.
5mg/
dL.

Hy
per
phosphat
emi
a
Asmal
lri
sei
nser
um phosphat
econcent
rat
ioni
ssuf
fi
cientt
ocauseadecr
easei
nser
um
i
oni
zedcal
cium.Ther
efor
e,ani
ncr
easei
nser
um phosphat
eresul
tsi
ncl
i
nical
mani
fest
ati
ons
f
rom hy
pocal
cemi
a.Hy
per
phosphat
emi
amayaf
fectmanyor
gans,
butdeposi
ti
onof
amor
phouscal
cium phosphat
eusual
l
yoccur
sinchr
oni
ccondi
ti
ons.Acut
ehy
per
phosphat
emi
a
i
sinv
ari
abl
yassoci
atedwi
thacut
ehy
pocal
cemi
a,whi
chmaybesev
ereenought
ocauset
etani
c
cr
amps.

Hy
pomagnesemi
a

Magnesi
um depl
eti
oni
scommoni
ntheI
CUf
rom l
ossofgast
roi
ntest
inal
flui
d,pr
olonged

par
ent
eral
nut
ri
ti
on,
orabdomi
nal
sur
gical
procedur
esassoci
atedwi
thdepl
etedmagnesi
um
st
ores100-
103(
Tabl
e8-
12)
.

CLI
NICALFEATURES

Thef
requentassoci
ati
onofmagnesi
um def
ici
encywi
thhy
pocal
cemi
a,hy
pokal
emi
a,and
al
kal
osi
smar
kedl
yconf
oundsi
tsci
i
nical
mani
fest
ati
ons.I
naddi
ti
on,
magnesi
um ad
mi
nist
rat
ional
oneof
tenr
esul
tsi
ncor
rect
ionofot
herl
abor
ator
yabnor
mal
i
ties.Thebi
o
chemi
cal
signi
fi
canceofhy
pomagnesemi
a,t
her
efor
e,r
emai
nssomewhatobscur
e.

Magnesi
um def
ici
encyr
eadi
l
yinducesmuscul
art
wit
chi
ng,
myocl
onus,
star
tl
ere
sponses,
andpost
ural
tremor
.104Tr
ousseau'
sandChv
ost
ek'
ssi
gns,
car
popedal
spasm,
and,
r
arel
y,t
etanyhav
eal
sobeenr
epor
tedbutt
hesear
emostchar
act
eri
sti
cofhy
pocal
cemi
a.I
n
manyaf
fl
ict
edpat
ient
s,br
iefper
iodsofanxi
etyandf
ear
,di
l
atedpupi
l
s,sweat
ing,
tachy
car
dia,
host
il
ebehav
ior
,andhal
l
uci
nat
ionsdev
elop,
associ
atedi
nsomewi
thdownbeatny
stagmus105
andat
axi
a.Unr
ecogni
zedsev
erehy
pomagnesemi
amaypr
edi
sposet
otoni
c-cl
oni
csei
zur
es.

TREATMENT

Hy
pomagnesemi
a,def
inedasapl
asmal
evel
of<1.
7mg/
dL,
shoul
dbet
reat
edi
mmedi
atel
y,
especi
all
yinpat
ient
swi
thsei
zur
es,
alt
hought
hreshol
dlev
elsar
egener
all
y<1mEq/
L
Magnesi
um sul
fat
einadoseof2gofa10%sol
uti
onshoul
dbeadmi
nist
eredov
era2-
min
per
iodandbef
oll
owedbyi
nfusi
onof12gi
n1Loff
lui
dov
era12-
hrper
iod.Amor
epr
udent
schedul
einpat
ient
swi
thl
essur
gentmani
fest
ati
onsi
sint
ramuscul
ari
nject
ionwi
th1gof
magnesi
um sul
fat
eev
ery4hr
.

Hy
per
magnesemi
a

Att
heneur
omuscul
arj
unct
ion,
magnesi
um compet
eswi
thcal
cium anddi
spl
acesi
tfr
om i
ts
t
argetsi
te.Asar
esul
t,r
eleaseofacet
ylchol
i
neand,
toal
argeext
ent
,theexci
tabi
li
tyoft
he
muscl
emembr
anedecr
ease.I
tseff
ect
sont
hecent
ral
ner
voussy
stem ar
elesswel
l
char
act
eri
zedbutmayber
elat
edt
ost
abi
l
izat
ionoft
hesy
napt
icmembr
ane,
whi
chl
eadst
o
decr
easedex
cit
abi
l
ity
.

Mostcommonl
y,hy
per
magnesemi
aoccur
swi
tht
heuseofmagnesi
um-
cont
aini
ng
ant
aci
dsandl
axat
ivesi
npat
ient
swi
thr
enal
fai
l
ureori
necl
ampt
icmot
her
s¹06(
Tabl
e8-
13)
(
Chapt
er13)
.Cl
i
nical
feat
uresgeneral
l
yappearwhenser
um magnesi
um l
evel
sexceed4mg/
dL.
Magnesi
um l
evel
sreachi
ng12mg/
dLal
mostcer
tai
nlyr
esul
tinsev
ereweaknessandar
efl
exi
a.

Thet
ypi
cal
neur
ologi
cmani
fest
ati
onsofmagnesi
um excessar
eusual
l
ynotpr
esenti
n
cl
i
nical
condi
ti
onswi
thoutexogenousi
ntakeofmagnesi
um.Chr
oni
crenal
fai
l
ure,
li
thi
um
t
her
apy
,hy
pot
hyr
oidi
sm,
hyper
par
athyr
oidi
sm wi
thr
enal
disease,
andpheochr
omocy
tomamay
al
lcauseapat
ientt
obesuscept
ibl
etoi
ncr
easesofser
um magnesi
um,
buti
nthesei
nst
ances,
t
ransmi
ssi
onbl
ockoft
heneur
omuscul
arj
unct
ioni
sgener
all
ynotcl
i
nical
l
yrel
evant
.

CLI
NICALFEATURES

I
ncr
easi
ngpl
asmal
evel
sofmagnesi
um l
eadt
onausea,
vomi
ti
ng,
cut
aneousf
lushi
ng,
anddr
y
mout
h.Adecr
easei
ntendonr
efl
exesi
sty
pical
.Insomepat
ient
s,pr
ogr
essi
onofl
i
mbweakness
i
srapi
dandbi
faci
alweaknessoccur
s.Ext
raocul
arandor
ophar
yngeal
muscl
esbecome
i
nvol
ved,
andsomepat
ient
smaybecome"
lockedi
n."Decr
easedl
evel
ofconsci
ousnessi
snota
f
eat
ureofhy
per
mag.nesemi
a.

TREATMENT
Gr
adual
impr
ovementov
erday
scanbeexpect
edwhennof
urt
heragnesi
um ormagnesi
um-
cont
aini
ngsubst
ancesar
eadmi
nist
ered.I
nsev
erecaseswi
thhear
tbl
ock,
cal
cium gl
uconat
e
(
10mLofa10%sol
uti
on)r
ever
seshy
per
magnesemi
a.Occasi
onal
l
y,pat
ient
sdonotr
ecov
er
compl
etel
y,andt
heymayhav
eunder
lyi
ngmy
ast
heni
csy
ndr
omes,

Hy
pocal
cemi
a

Hy
pocal
cemi
asi
gni
fi
esapoorpr
ognosi
sinpat
ient
swhoar
ecr
it
ical
l
yil
l
.Causesf
requent
ly
encount
eredi
ntheI
CUar
eoutl
i
nedi
nTabl
e8-
14.
108.
109Appr
oxi
mat
elyhal
fthet
otal
ser
um
cal
ci
um i
spr
otei
nbound,
pri
mar
il
ybyal
bumi
n.Di
ff
erencesi
nser
um al
bumi
nconcent
rat
ionand
st
ateofhy
drat
ionmaycausev
ari
ati
onsi
nser
um t
otal
cal
cium concent
rat
ion.
110Theef
fectof
al
bumi
ncanbecor
rect
edbyuseoft
hef
oll
owi
ngf
ormul
a:adj
ust
edmeasur
edser
um cal
cium =
ser
um cal
cium +0.
8(4-ser
um al
bumi
n).Adecr
easei
ntheconcent
rat
ionofser
um al
bumi
nby
1g/
dLpr
oducesadecr
easei
ntot
alser
um cal
cium f
rom 0.
8to1mg/
dL,
butt
hei
oni
zed
f
ract
ionofcal
cium r
emai
nsunchanged.Hy
pocal
cemi
aassoci
atedwi
thhy
poal
bumi
nemi
adoes

notcausesy
mpt
omsbecauset
hei
oni
zedf
ract
ionr
emai
nssi
mil
ar.

CLI
NICALFEATURES

Si
gnsandsy
mpt
omsofhy
pocal
cemi
ahav
ebeenwel
lchar
act
eri
zed,
butmanypat
ient
smaybe
asy
mpt
omat
icandi
tisonl
yar
efl
ect
ionofsev
eri
tyofi
l
lness.111-
115Par
est
hesi
asi
nthe
handsandf
eetandar
oundt
hel
i
psar
eear
lysi
gnsbutal
mostcer
tai
nlygounnot
icedi
ncr
it
ical
l
y
i
l
lpat
ient
s.Muscl
ecr
amps,
car
popedal
spasm,
andl
ary
ngeal
str
idormayf
oll
owas
hy
pocal
cemi
apr
ogr
esses.Pl
ant
arf
lexi
onoft
het
oes,
archi
ngoft
hef
eet
,andcont
ract
ionof
cal
fmuscl
esmayal
sobecar
dinal
signs.

Chv
ost
ek'
ssi
gni
sfr
equent
lyf
ound,
andt
hist
ypi
cal
signi
nhy
pocal
cemi
aisel
i
cit
edby
t
appi
ngt
hreef
inger
sov
ert
hebr
anchesoft
hef
aci
alner
veant
eri
ort
otheext
ernal
audi
tor
y
meat
us.Aposi
ti
ver
esponsei
sindi
cat
edbyt
wit
chi
ngofal
li
psi
l
ater
alf
aci
almuscl
es(
li
pat
angl
eofmout
h,nasal
bri
dge,
andl
ater
alangl
eofey
e),
alt
hought
her
emaybeagr
adedr
esponse.
Twi
tchi
ngoft
hemout
hal
oneshoul
dnotbei
nter
pret
edasdi
agnost
ic,
becausei
tpat
ient
s116
mayoccuri
n25%ofnor
mal
pat
ient
s.Lat
entt
etanymayal
sobedem onst
rat
edwhenabl
ood
pr
essur
ecuf
fononeol
i
cbl
oodpr
esar
misi
nfl
atedabov
ethesy
stol
i
csur
e(Tr
ousseau'
ssi
gn)
f
oratl
east5mi
n.17Fl
exi
onoft
hef
inger
sandadduct
ionoft
het
humbpr
oduceacar
popedal
spasm,
ormai
nd'
accoucheur(
obst
etr
ici
an'
shand)
.

Toni
c-cl
oni
csei
zur
esoccurwhenser
um cal
cium concent
rat
ioni
s<3mEq/
L.I
noc
casi
onal
cases,
focal
ornonconv
ulsi
vest
atusepi
l
ept
icusmaydev
elop.Sei
zur
esst
opaf
ter
cor
rect
ionofhy
pocal
cemi
a,butgr
andmal
sei
zur
esmayev
olv
eint
oconv
ulsi
vest
atusep
i
l
ept
icus.Pr
olongedcomaf
rom hy
pocal
.cemi
asel
dom occur
s;i
fitdoes,
iti
susual
l
yther
esul
t
ofanoxi
aassoci
atedwi
thl
ary
ngeal
str
idororpoor
lycont
rol
l
edst
atusepi
l
ept
icus.

TREATMENT

Hy
pocal
cemi
acanbepr
ompt
lycor
rect
edbya2-
hri
ntr
avenousi
nfusi
onwi
th20t
o40mLofa
10%sol
uti
onofcal
cium gl
uconat
efol
lowedbyor
aladmi
nist
rat
ionofcal
cium,
5g/
day
.Muscl
e
spasm,
howev
er,
mayper
sistf
orsev
eral
hour
saf
ternor
mal
i
zat
ionoft
hecal
cium concent
rat
ion.
Vi
rt
ual
l
ynopat
ienthasmaj
orneur
ologi
csequel
aeaf
tert
reatment
.

Hy
per
cal
cemi
a

Hy
per
cal
cemi
amayr
esul
tfr
om pr
imar
yhyper
par
athy
roi
dism andmal
i
gnantdi
seasewi
thor
wi
thoutmet
ast
asi
s.Neur
ologi
cmani
fest
ati
onsar
enonspeci
fi
candar
eusual
l
yfoundi
n
pat
ient
swi
thsi
gni
fi
cantdehy
drat
ion.Fi
ndi
ngsi
ncl
udemar
keddr
owsi
nessandi
mpai
red
concent
rat
ion,
whi
choccasi
onal
l
ypr
ogr
esst
ocoma.Mánypat
ient
srecov
eraf
tergener
al
measur
eshav
ebeent
akent
ocor
rectdehy
drat
ion.

ENDOCRI
NEEMERGENCI
ES

Pat
ient
swi
thacut
eendocr
inedi
stur
bancesar
eof
tengr
avel
yil
l
,cl
i
nical
mani
fest
ati
onsar
e
dr
amat
ic,
andneur
ologi
cmani
fest
ati
onsar
ecommon.Att
heot
herendoft
hespect
rum,
st
ressor
sint
heI
CU,
whet
hermaj
orsur
gical
procedur
esori
nfect
ion,
maychal
l
enget
he
endocr
ineaxi
s.

Nonket
oti
cHy
per
osmol
arSt
ate

Thephy
siol
ogi
cchangesi
nnonket
oti
chy
perosmol
arst
ate(
NKHS)ar
epr
edomi
nant
lyhy
per
gly
cemi
awi
thnooronl
ymi
nimal
ket
osi
sandext
remedehy
drat
ion,
ref
lect
edi
ngr
eat
ly
i
ncr
easedpl
asmaosmol
ali
ty.Ty
peI
ldi
abet
eshasbeenundi
agnosedatt
het
imeofpr
esen
t
ati
oni
none-
thi
rdofpat
ient
swi
thNKHS.I
not
herpat
ient
swi
tht
ypeI
Idi
abet
es,
int
ercurr
ent
i
nfect
ionandf
ail
uret
oachi
eveadequat
ehy
drat
iont
ri
ggert
heder
angement
.

Nonket
oti
chy
per
osmol
arst
ate

canoccurasacompl
i
cat
ionofanybact
eri
ali
nfect
ionorsept
icshock,
ext
ensi
vebur
ns,
acut
e
pancr
eat
it
is,
hyper
ali
ment
ati
on,
useofcor
ti
cost
eroi
ds,
andper
it
oneal
dial
ysi
s(Tabl
e8-
15)
.
Howev
er,
post
oper
ati
veNKHSi
sver
ycommon,
and,
inf
act
,mostpat
ient
swi
thNKHSar
eseen
i
nsur
gical
ICUs.118,
119Thi
sdi
sor
dercanbet
ri
gger
edbydr
ugswi
th.
aknownhy
per
gly
cemi
c
ef
fect(
forexampl
e,f
urosemi
de,
dopami
ne)orbyf
everi
nthef
ir
stday
saf
termaj
orsur
gica!
pr
ocedur
es.Seki
¹19f
oundt
hat
,onav
erage,
NKHSoccur
redont
hesi
xthdayaf
tercor
onar
yby
pass(
range,
3to10day
s).Met
icul
ousatt
ent
iont
oear
lycl
i
nical
signsandf
requentser
um
gl
ucosedet
ermi
nat
ionsmaypr
eventpat
ient
swi
tht
ypeI
Idi
abet
esmel
l
itusf
rom l
apsi
ngi
nto

t
hispot
ent
ial
l
yfat
alcompl
i
cat
ion.
CLI
NICALFEATURES

Thecl
assi
cfeat
uresofNKHSconsi
stofdecr
easei
nlev
elofconsci
ousness,
progr
essi
ve
sl
i
ppi
ngi
ntodeepcoma,
andbar
elyapparentmot
orr
esponsest
opai
n.Nonket
oti
chy
per
gly
cemi
ccomaoccur
swi
thasi
xfol
dtot
enf
oldi
ncr
easei
nser
um gl
ucose.Occasi
onal
l
y,
f
ocal
signsorf
ocal
sei
zur
esar
ethepr
esent
ingi
ndi
cat
ions.120-
123I
nit
smostacut
efor
m,t
he
sy
ndr
omecanbemani
fest
edbyr
efr
act
oryst
atusepi
l
ept
icus.Focal
neur
ologi
csi
gnst
hatl
ead
admi
tt
ingphy
sici
anst
obel
i
evet
hatt
hei
rpat
ient
shav
ehadast
rokear
eaphasi
a,hemi
par
esi
s,
andv
isual
fiel
ddef
ect
s,whi
chhav
ebeenr
epor
tedi
none-
thi
rdofpat
ient
s.Focal
neur
ologi
c
si
gnsar
efoundv
irt
ual
l
yonl
yint
henonket
oti
chyper
osmol
arst
ateandar
ecommonl
yabsenti
n
ot
hermet
abol
i
cder
angement
s.Thephenomenoni
sdi
ff
icul
ttoexpl
ain,
butpr
evi
oussi
l
ent
st
rokes,
par
ti
cul
arl
yint
hesepat
ient
s.wi
thmaj
orcer
ebr
ovascul
arr
iskf
act
ors,
maybecome
mor
eappar
entdur
inghy
per
gly
cemi
a.Tr
ansi
entbi
l
ater
alBabi
nski
'
ssi
gns,
muscl
etwi
tchi
ng,
and
t
oni
cey
edev
iat
ionmayal
sooccur
.Inpat
ient
swi
thl
esssev
erehy
per
gly
cemi
a,f
ocal
sei
zur
es
maydomi
nat
ethecl
i
nical
pict
ure.Ar
evi
ewof158pat
ient
snot
edsei
zur
esi
naboutone-
four
thof
t
hepat
ient
swi
thNKHSandf
ocal
mot
orsei
zur
esi
n19%.Epi
l
epsi
apar
ti
ali
scont
inua,
howev
er,
gener
all
yoccur
sinpat
ient
swi
thapr
eexi
sti
ngst
ruct
ural
lesi
on,
usual
l
yasar
esul
tofanear
li
er
i
schemi
cst
roke.
"Unusual
typesoff
ocal
epi
l
epsy
,incl
udi
ngst
ereot
ypi
cal
mov
ement
s,speech
ar
rest
,andf
lashi
ngcol
oredl
i
ght
s,hav
eal
sobeendescr
ibedi
npat
ient
swi
thnonket
oti
c
hy
per
gly
cemi
a.Uncommonmani
fest
ati
onsar
eopsocl
onusmy
ocl
onus,
chor
eoat
het
osi
s,
hemi
bal
l
ismus,
andpost
ure-
inducedsei
zur
es(
cloni
candbr
ief
jer
kingmov
ement
str
igger
edby
act
iveorpassi
vechangei
nheadorar
m posi
tion)
.12TheMRIst
udi
esi
nthesepat
ient
s
document
edt
ransi
entT2si
gnal
changesi
ntheput
amenorcaudat
enucl
eus

Neur
ologi
csi
gnsandt
hedegr
eeofdecr
easei
nthel
evel
ofconsci
ousnessappeart
o
hav
eabet
tercor
rel
ati
onwi
thpl
asmaosmol
ali
ty(
Fig.8-
5)andser
um sodi
um l
evel
thanwi
th
absol
uteser
um gl
ucoseconcent
rat
ion75,
128

I
npat
ient
swi
thnonket
oti
chy
per
osmol
arst
ates,
hyponat
remi
aof
tenoccur
sbecause
i
ncr
easedosmot
icpr
essur
efr
om hy
per
glycemi
ashi
ft
sfl
uidf
rom cel
l
sint
otheext
racel
l
ular
f
lui
dspace.Despi
tehy
ponat
remi
a,ahy
per
osmol
arst
ateexi
sts,
andef
for
tsshoul
dbedi
rect
ed
t
ocor
rect
ingt
hehy
perosmol
ar-
hyper
gly
cemi
cst
ateandnott
hehyponat
remi
aperse.

Thecor
rect
edser
um sodi
um v
alue(
adecr
easeof2.
4mEq/
Linsodi
um concent
rat
ion
per100mg/
dl.i
ncr
easei
ngl
ucoseconcent
rat
ion)i
sbet
tert
hant
he"
1.6"corr
ect
ionf
act
or,
Pat
ient
swi
thhy
ponat
remi
abutnor
mal
cor
rect
edser
um sodi
um concent
rat
ions,
incr
eased
pl
asmaosmol
ali
ty,
andhy
per
gly
cemi
ausual
l
ydonothav
eneur
ologi
csi
gns,
because
dehy
drat
ioni
sli
mit
ed.Ont
heot
herhand,
pat
ient
swi
thanor
mal
,l
ow,
orhi
ghser
um sodi
um

l
evel
butahi
ghcor
rect
edser
um sodi
um v
aluewhoar
einahy
per
gly
cemi
candhy
per
osmol
ar
st
atemayhav
easev
erel
ydepr
essedconsci
ousness.

TREATMENT

Nonket
oti
chy
per
osmol
arcomai
sassoci
atedwi
thhy
pov
olemi
a,whi
chexpl
ainshy
pergl
ycemi
a
(
euv
olemi
awoul
dresul
tini
ncr
easedsecr
eti
onofgl
ucoseandpr
eventhi
ghconcent
rat
ioni
nthe
bl
ood)
.Acr
uci
alel
ementi
nthet
reat
mentofnonket
oti
chyper
osmol
arcomai
srehy
drat
ionwi
th
i
sot
oni
csal
i
net
oest
abl
i
shadequat
efi
l
li
ngoft
hei
ntr
avascul
arcompar
tment
.Insul
i
ntherapy
canbewi
thhel
dbecauseof(
unpr
oven)concer
nst
hatt
hecombi
nat
ionwi
thr
ehydr
ati
onwi
l
l
i
nducecer
ebr
aledema.

Out
comei
nnonket
oti
chy
per
osmol
arcomai
sgener
all
ydet
ermi
nedbyear
lyr
ecogni
ti
on
andpr
opermeasur
es.Whet
heraggr
essi
vecor
rect
ionoft
hehy
per
osmol
ali
tyr
esul
tsi
n
secondar
yinsul
tst
othebr
aini
snotsuppor
tedbycl
i
nical
dat
a.Al
so,
vir
tual
l
ynol
ong-
ter
m
out
comedat
aar
eav
ail
abl
eonpat
ient
swhosur
viv
ethei
nsul
t.Wi
thonet
hir
doft
heout
comes
f
atal
inmostmedi
cal
andsur
gical
ser
ies,
mor
tal
i
tyr
emai
nsunaccept
abl
yhi
gh.Themost
commoncauseofdeat
hist
heunder
lyi
ngdi
seaset
hatt
ri
gger
edcoma.

Di
abet
icKet
oaci
dot
icComa

Thehal
l
mar
ksoft
hisdi
sor
derar
esev
erehyper
gly
cemi
a,ket
oaci
dosi
s,andhy
per
osmol
ari
ty.
Fr
equent
ly,
pat
ient
sar
eknownt
ohav
eype1(
juv
eni
l
e-onset
)di
abet
es,
wher
easnonket
oti
c
hy
per
osmol
arcomamor
eof
tenoccur
sint
ypeI
ldi
abet
es.Ket
oaci
dot
iccoma,
howev
er,
maybe
apr
esent
ingf
eat
ureofdi
abet
esmel
l
itus

Hy
per
osmol
ari
tymaybel
esspr
omi
nenti
nket
oaci
dosi
sthani
nthenonket
oti
cst
ate,
but
agai
ndegr
eeofdr
owsi
nessmaybemor
epr
opor
ti
onal
tot
hesev
eri
tyofdehy
drat
ion(
Fig.8-
5).
Al
arger
etr
ospect
ivest
udyof287epi
sodesofdi
abet
icket
oaci
dosi
sfoundonl
yaweak
cor
rel
ati
onbet
weenHconcent
rat
ionsandt
hedegr
eeofcomaandconf
ir
medt
hecl
i
nical
i
mpr
essi
ont
hatmanydi
abet
icpat
ient
swi
thsev
eremet
abol
i
caci
dosi
sar
eal
ert
.

Focal
signsar
eext
remel
yuncommoni
nket
oaci
dot
iccomaandshoul
dsuggestan
under
lyi
ngst
ruct
ural
cause.Ful
minantbact
eri
almeni
ngi
ti
sshoul
dbeconsi
der
edi
nanypat
ient
wi
thdi
abet
iccomaunr
esponsi
vet
ofl
uidr
esusci
tat
ion(
seeChapt
er6)
.

Onl
ygener
algui
del
i
nest
otr
eat
mentofdi
abet
icket
oaci
dot
iccomacanbegi
venbe
causer
andomi
zedt
ri
alsar
elacki
ng.Mostexper
tsi
nthi
sfi
eldf
avori
nfusi
onwi
thsal
i
ne,
100t
o
150nmol
/Li
nthef
ir
st12hrand50t
o70mmol
/Lt
her
eaf
ter
.131Asmal
lrandomi
zedst
udyon
t
heef
fectofaddi
ti
onal
bicar
bonat
einf
usi
onshowednoadv
ant
agei
npat
ient
swi
thani
nit
ial
pH
of6.
9to7.
1.1Ast
udycompar
ingdi
ff
erentr
egi
mensofi
nsul
i
nther
apyconcl
udedt
hat
i
ntr
avenousi
nfusi
onofi
nsul
i
n(l
owdoses)
,sal
i
ne,
anddext
rose,
wit
htheaddi
ti
onof
bi
car
bonat
eonl
yift
hepHwas<7,
1,wassuper
iort
oot
herr
egi
mens1Useofcol
l
oidi
nan
at
temptt
orest
oret
heci
rcul
ati
ngv
olumei
snotsuppor
tedbyanycont
rol
l
edt
ri
alandi
snotwi
th
outr
iskandexpense13

Mostpat
ient
ssur
viv
ethemet
abol
i
cder
angementwi
thoutanysi
gni
fi
cantr
esi
dual
def
ici
tCer
ebr
aledemadur
ingt
reat
mentofdi
abet
icket
oaci
dosi
sisar
arebutnear
lyuni
for
mly
f
atal
compl
i
cat
ion.Theoccurr
enceofmassi
vecer
ebr
aledema,
most
lyi
nchi
l
drenand
adol
escent
s,i
sunpr
edi
ctabl
e.andpat
ient
sathi
ghr
iskhav
enotbeeni
dent
if
ied,

Thecl
i
nical
present
ati
onofcer
ebr
aledemaassoci
atedwi
tht
reat
mentofdi
abet
ic
aci
dosi
sisst
ri
ki
ng.Af
teri
nit
ial
biochemi
cal
andcl
i
nical
impr
ovement
,thepat
ientr
api
dlysl
i
ps
backi
ntocomawi
thspont
aneousext
ensorpost
uri
ng,
soonf
oll
owedbyf
ixedanddi
l
atedpupi
l
s.
Thecl
i
nical
cri
ter
iaf
orbr
aindeat
har
epr
esentwi
thi
n1t
o2hri
npat
ient
swi
thmassi
vecer
ebr
al
edema.I
ncr
easedmuscl
etone,
gegenhal
ten,
orf
ocal
sei
zur
esmayher
aldt
hedr
owsi
ness.Pa
pi
l
ledemamaybepr
esentbutonl
yinpat
ient
swi
thpr
ogr
essi
ont
obr
aindeat
hduet
omassi
ve
bi
hemi
spher
icswel
l
ingacut
elyi
ncr
easi
ngi
ntr
acr
ani
alpr
essur
e.Thecl
assi
cst
agesof
t
ranst
ent
ori
alher
niat
ionar
eusual
l
ynotpr
esent
,andmostpat
ient
shav
esuddenr
espi
rat
ory
ar
restandi
mmedi
atel
ossofbr
ainst
em r
efl
exes.

Tr
eat
mentwi
thmanni
tol
,fl
uidr
est
ri
cti
on,
andcor
ti
cost
eroi
dsi
sunsuccessf
uli
nmost
cases,
butr
api
dini
ti
ati
onofmanni
tol
(2g/
kgofbodywei
ght
)andf
lui
drest
ri
cti
on(
1.3L/
m²per
24hr
)occasi
onal
l
ysal
vagespat
ient
s.Cl
i
nical
det
eri
orat
ionmayoccurupt
o24hraf
teri
nit
iat
ion
oft
her
apy
.Fav
orabl
eout
comehasbeenr
epor
ted,
butmanypat
ient
smayhav
eresi
dual
sev
ere
cogni
ti
vedef
ici
tsandat
axi
a.

Comput
edt
omogr
aphyscanni
ngmaydemonst
rat
esi
gnsofcer
ebr
aledema,
mar
kedby
decr
easei
nsi
zeoft
hel
ater
alv
ent
ri
clesandobl
i
ter
ati
onoft
heambi
entci
ster
ns.Twoser
ial
CT
scanst
udi
esshowedt
hatbr
ainswel
l
ing(
def
inedasdecr
easedsi
zeofv
ent
ricl
esorci
ster
ns)
waspr
esentbef
oret
reat
ment
,wasl
argel
yunchangedaf
ter6t
o8hroft
reatment
,andr
esol
ved
si
gni
fi
cant
lyaweekaf
tert
reat
ment13,
140Fat
alcer
ebr
aledema,
howev
er,
didnotoccur
,
Hof
fmanandassoci
atest
her
efor
erai
sedt
hepossi
bil
i
tyt
hatf
atal
edemadur
ingt
reat
mentmay
bemer
elyapr
ogr
essi
onofanal
readyi
nit
iat
edphy
siol
ogi
cpr
ocess.Pat
ient
swhosur
viv
ebr
ain
edema,
howev
er,
mayr
emai
ndi
sabl
edbyi
nfar
ctsi
nthedi
str
ibut
ionoft
heant
eri
orcer
ebr
al
ar
ter
yandt
hal
ami
cper
for
ati
ngar
ter
iesduet
omechani
cal
compr
essi
onorst
ret
chf
rom acut
e
downwar
ddi
spl
acementoft
hebr
ainst
em f
rom edema.Thesei
nfar
ctscanbedocument
edby
CT.

PATHOPHYSI
OLOGI
CMECHANI
SMS

Twomaj
orhy
pot
heseshav
eemer
gedov
ert
hey
ear
s.Cer
ebr
aledemamaybeexpl
ainedi
n
t
ermsofi
diogeni
cosmol
est
hatser
vet
opr
otectbr
ainf
rom shr
inkageatt
het
imeofpr
ofound
dehy
drat
ion.Unf
ort
unat
ely
,thesemol
ecul
esmaysl
owl
ydi
ssi
pat
e,andt
hei
runwant
ed
pr
esencemayconsequent
lyl
eadt
obr
ainedemawhenf
lui
dinf
usi
onr
api
dlyr
esul
tsi
nahy
po
osmot
icst
ate.Howev
er,
thi
shy
pot
hesi
slacksgoodsuppor
t,becausenocor
rel
ati
oncoul
dbe
f
oundwi
thanyoft
hef
oll
owi
ngt
reat
mentmodesorbi
ochemi
cal
fact
ors:
excessi
vehy
pot
oni
c
f
lui
drepl
acement
,ser
um sodi
um v
alues,
osmol
ali
ty,
andi
nsul
i
npr
otocol
s.Ot
her
shav
e
suggest
edt
hataNa*
/H+exchangermaybei
nvol
ved,
142Thi
shy
pot
hesi
swoul
dindeedsuppor
t
t
hepr
etr
eat
mentsubcl
i
nical
presenceofcer
ebr
aledemaandt
empor
alr
elat
ionwi
thi
nsul
i
nand
f
lui
dtr
eat
ment
.

Thi
sNa+/
H+exchangercanbeact
ivat
edbyi
nsul
i
n,asconv
inci
ngl
ydemonst
rat
edi
n
ot
hert
issues(
forex
ampl
e,muscl
e).143Thi
sact
ivat
ionr
esul
tsi
nsodi
um i
nfl
uxi
ntot
hecel
l
s
andbr
ainswel
l
ing.Ther
emaybear
ati
onal
eforNa/
Hexchangeri
nhi
bit
orssuchasami
l
ori
de
(
whi
ch,
ont
hebasi
sofmol
ecul
arpr
oper
ti
es,
shoul
dbeabl
etocr
osst
hebl
ood-
brai
nbar
ri
er)
,
142butcl
i
nical
andexper
iment
alst
udi
eshav
enoty
etbeenper
for
med.

Ar
ecentst
udyi
nchi
l
drensuggest
edt
hatbr
aini
schemi
afol
l
owedbyedemahasar
ole

becauseoft
hesi
gni
fi
cantassoci
ati
onwi
thhy
pocapni
a(v
asoconst
ri
cti
on)andhi
ghi
nit
ial
ser
um
ur
eani
tr
ogenconcent
rat
ions(
dehy
drat
ion)
.Bi
car
bonat
ether
apymayaddi
ti
onal
l
yreduce
cer
ebr
ospi
nal
flui
dpar
ti
alpr
essur
eofoxy
genandexacer
bat
evasoconst
ri
cti
on144

Hy
pogl
ycemi
a

I
nmostpat
ient
sint
hehospi
tal
orI
CU,
ahypogl
ycemi
cepi
sodei
saconsequenceoft
reat
ment
wi
thi
nsul
i
n.I
not
her
s,i
nadequat
emanagementofpar
ent
eral
nut
ri
ti
oncanbehel
dresponsi
ble
f
orsy
mpt
omat
icepi
sodesofhy
pogl
ycemi
a.145

Useofbet
a-bl
ocker
smaygener
atehy
pogl
ycemi
aini
nsul
i
n-t
reat
eddi
abet
icpat
ient
sbut
,
mor
eimpor
tant
ly,
mayal
somaskt
ypi
cal
sympt
omsofhy
pogl
ycemi
a,suchast
achy146car
dia,
sweat
ing,
andt
remor
.Thesesy
mpt
omsofhy
per
epi
nephr
inemi
amayt
heor
eti
cal
l
yal
sogo
unnot
icedi
nheav
il
ysedat
edpat
ient
sint
heI
CU.Ot
hert
ri
gger
ingev
ent
sforsi
gni
fi
cant
hy
pogl
ycemi
aar
eful
minanthepat
icf
ail
ure,
sepsi
s,anddr
ugswi
thst
imul
ati
ngef
fect
soni
nsul
i
n
(
Tabl
e8-
16)
.

Thesy
mpt
omsofhy
pogl
ycemi
aar
epr
oducedbyanadr
ener
gicr
eact
ionandi
ncl
ude
pal
l
or,
sweat
ing,
tachy
car
dia,
sensat
ionofhunger
,anxi
ety
,andpal
pit
ati
ons.(
Theaut
hori
s
awar
eofsev
eral
inst
ancesi
nwhi
cht
heseev
ent
swer
emi
sint
erpr
etedasI
CUpsychosi
s.)

Neur
ologi
csy
mpt
omscannotbepr
edi
ctedf
rom bl
oodgl
ucosel
evel
s,butt
hedept
hof
comamayhav
esomecor
rel
ati
onwi
tht
hedegr
eeofhy
pogl
ycemi
a.Sur
pri
singl
y,somepat
ient
s
wi
thsev
erebi
ochemi
cal
hypogl
ycemi
aar
eful
l
yawakeoronl
ymi
l
dlydi
sor
ient
ed.When
hy
pogl
ycemi
adev
elopssl
owl
y,bl
urr
edv
isi
onandsl
urr
edspeechar
epr
omi
nent
.145,
146
Pat
ient
swwhobecomecom at
osequi
ckl
yawakenaf
teri
ntr
avenousadmi
nist
rat
ionofgl
ucose
butmayr
emai
nunconsci
ousaf
terpr
olongedhy
pogl
ycemi
ccomaoraf
teraconcomi
tantt
oni
c-
cl
oni
csei
zur
e.Sei
zur
esi
nhy
pogl
ycemi
amayoccuri
ndi
abet
icpat
ient
swi
thpr
evi
ousst
rokes
andr
api
dshi
ft
sinbl
oodgl
ucoseconcent
rat
ion.I
npr
obabl
ythel
argestser
iesofpat
ient
swi
th
sy
mpt
omat
ichy
pogl
ycemi
aadmi
tt
edt
oanemer
gencyr
oom,
9of125v
isi
tswer
eassoci
ated
wi
thsei
zur
es,
usual
l
ytoni
c-cl
oni
c,butmostpat
ient
shadasei
zur
edi
sor
deroral
cohol
dependency
.Theneur
ologi
cmani
fest
ati
onsofhy
pogl
ycemi
aar
esummar
izedi
nTabl
e8-
17.

Thepr
inci
pal
signsandsy
mpt
omsofhypogl
ycemi
aar
ebehav
iorchangesmar
kedby
conf
usi
on,
vacantst
are,
or,
int
heext
remesi
tuat
ion,
unr
esponsi
venesst
opai
nst
imul
i
.Mar
ked
chor
ioat
het
osi
swi
thf
aci
algr
imaci
ngatt
het
imeofhy
pogl
ycemi
ahasbeenr
epor
ted.148
Tr
ansi
enthemi
plegi
ahasbeenassoci
atedwi
thsev
erehy
pogl
ycemi
a.147Normal
i
zat
ionof
bl
oodgl
ucoseconcent
rat
ionr
esul
tsi
nresol
uti
onofhemi
plegi
awi
thi
nmi
nut
es.

Epi
sodesofhy
pogl
ycemi
aar
etr
eat
edwi
thgl
ucosei
nther
angeof25t
o50mLof50%
sol
uti
on,
andf
urt
herdet
eri
orat
ionshoul
dbepr
event
ed,
oft
enwi
thsi
mpl
emeasur
es.Sev
ere
hy
pogl
ycemi
creact
ionsmayal
sobet
reat
edwi
thgl
ucagon.Asal
l
udedt
oear
li
er,
mostpat
ient
s
r
ecov
ercompl
etel
y.Thedel
ayi
nrecogni
ti
onandt
hedur
ati
onofcomapr
obabl
ydet
ermi
ne
neur
ologi
csequel
ae.Pat
ient
swi
thhy
pogl
ycemi
ccomaofl
ongdur
ati
on(
est
imat
edt
obef
rom
4t
o6hr
)hav
eagr
eatchanceofper
sist
entv
eget
ati
vest
ateorsev
eredi
sabl
i
ngcer
ebel
l
arsi
gns.
149

Manypat
ient
sinwhom aut
opsywasperf
ormedaf
terpr
olongedhy
pogl
ycemi
ccoma
hadsel
ect
iveneur
onal
vul
ner
abi
l
ityconsi
sti
ngofdamagei
nthehi
ppocampus,
str
iat
um,
subst
ant
iani
gra,
and,
par
ti
cul
arl
y,t
hecer
ebel
l
um.150-
152Associ
atedhy
pot
ensi
onormar
ked
hy
poxi
afr
om gast
ri
caspi
rat
ionorhy
pov
ent
il
ati
oni
npat
ient
swi
thpr
olongedhy
pogl
ycemi
amay
beaconf
oundi
ngf
act
or.Damagei
nthehi
ppocampusmaynowber
ecogni
zedonMRI(
Fig.8-
6).

Thy
roi
dSt
orm

Anendocr
inedi
sor
derofmaj
ori
mpor
tancei
ssuddent
hyr
otoxi
cosi
s.Thy
roi
dst
ormf
requent
ly
occur
sinpat
ient
swi
thi
ncompl
etecont
rol
butmaybet
hef
ir
stpr
esent
ati
onoft
hyr
oid
i
mbal
ance.
153Thekeycl
i
nical
feat
ures(
Tabl
e8-
18)ar
ehy
per
ther
mia,
tachycar
dia,
and
del
i
rium.
154Ear
lyi
nthecour
se,
pat
ient
smaybeanxi
ous,
ner
vous,
andov
err
eact
ive,
Mar
ked
psy
chi
atr
icsy
mpt
omswi
thv
ivi
dvi
sual
andacoust
ichal
l
uci
nat
ionsar
eoccasi
onal
l
ypr
esent
.

155.
156Unt
reat
edpat
ient
slapsei
ntocomaandmayhav
eext
ensorpost
uri
ngorpat
hol
ogi
c
f
lexi
onr
esponses,
promi
nentpy
rami
dal
signswi
thpr
ofoundspast
ici
ty,
pat
hol
ogi
cbr
ainst
em
r
efl
exes,
bil
ater
alcl
onus,
andBabi
nski
'
ssi
gns.
157El
der
lypat
ient
smaydi
spl
ayadi
sti
nct
ive

cl
i
nical
syndr
omeofapat
het
ict
hyr
otoxi
cosi
s(pat
ient
swho"
qui
etl
yandpeacef
ull
ysi
nki
nto
comaanddi
eanabsol
utel
yrel
axeddeat
h")
.158Ot
herdi
sti
nct
ivef
eat
uresofapat
het
ic
t
hyr
otoxi
cosi
sar
epr
ofoundbl
ephar
opt
osi
s(butnopr
opt
osi
s)andpr
oxi
mal
myopat
hy.Pat
ient
s
wi
thsev
eret
hyr
otoxi
cosi
smor
eof
tenhav
eper
ior
bit
alpuf
fi
nessandpr
opt
osi
s,whi
chmaybe
mor
epr
oini
nentuni
l
ater
all
y.Hy
per
ther
mia(
oft
en>39.
5°C)wi
thexcessi
vesweat
ingandmoi
st
ski
nisatr
atherspeci
fi
csy
mpt
om.Mul
ti
nodul
art
hyr
omegal
yisanot
herf
requentf
indi
ngbut
maybeabsenti
n10%oft
hepat
ient
s.
 Hy
per
thy
roi
dism maybeaccompani
edbyacut
ethy
rot
oxi
cmy
opat
hy.
159Thi
sent
it
yis
char
act
eri
zedbyr
api
dmuscul
arweaknessassoci
atedwi
thdi
aphr
agmat
icf
ail
ure,
but
unf
ort
unat
ely
,accur
atedocument
ati
oni
sscar
ce.Tocompl
i
cat
emat
ter
sfur
ther
,thyr
otoxi
cosi
s
maybeassoci
atedwi
thmy
ast
heni
agr
avi
sandf
ami
l
ial
per
iodi
cpar
aly
sis.Thy
rot
oxi
cst
orm
mayal
sor
esul
tinr
habdomy
oly
sis.

Pr
omptt
reat
mentwi
thpr
opy
lthi
our
aci
l
,pr
opr
anol
ol,
andcor
ti
cost
eroi
dsr
esul
tsi
na
f
avor
abl
eout
come.Excessci
rcul
ati
ngt
hyr
oidhor
monemayal
sober
emov
edbypl
asma
exchangeorper
it
oneal
dial
ysi
s.Emer
gencyt
hyr
oidsur
ger
ymaybei
ndi
cat
edi
npat
ient
swi
th
t
hyr
oidst
orm notcont
rol
l
edbyt
hesemeasur
es.Fat
alout
comemaybeaconsequenceof
i
rr
ever
sibl
econgest
ivehear
tfai
l
ure,
ext
remedehy
drat
ion,
andhy
pogl
ycemi
a,butmanypat
ient
s

sur
viv
e.

Hashi
mot
o'sEncephal
opat
hy

Af
asci
nat
ingneur
ologi
cdi
sor
derhasbeenl
i
nkedt
oaut
oimmunet
hyr
oidi
ti
s(Hashi
mot
o's
encephal
opat
hy)
.Theant
it
hyr
oidant
ibodyt
it
ers,
par
ti
cul
arl
ythoseoft
heant
it
hyr
oidper
oxi
dase
ant
ibodi
es,
areel
evat
ed.Thy
roi
d-st
imul
ati
nghor
mone,
butnott
hyr
oidhor
mone,
isusual
l
y
mar
kedl
yincr
eased,
alt
houghhy
pot
hyr
oidi
sm mayev
olv
elat
er.Conf
usi
onal
stat
e,my
ocl
onus,
hal
l
uci
nat
ions,
andapanopl
yofpsy
chi
atr
icmani
fest
ati
onsshoul
dpoi
ntt
othepossi
bil
oft
his
r
aredi
sor
der
.it
yofr
aredi
sor
der

Magnet
icr
esonancei
magi
ngmaydocumentadi
ff
usel
eukoencephal
opat
hy(
Fig.8-
7),
butf
indi
ngsmaybenor
mal
inf
lor
idcases.Sl
owi
ngoft
heel
ect
roencephal
ogr
aphi
cpat
ter
n
i
nter
rupt
edbyf
ocal
epi
l
ept
if
orm abnor
mal
i
tieshasbeenr
epeat
edl
ydocument
edbutwi
thout
speci
fi
cchar
act
eri
sti
cs.Oneaut
opsydocument
edav
ascul
i
tici
nfi
l
trat
einv
enul
es,
suggest
ing
v
ascul
i
tis.Responset
oint
rav
enousadmi
nist
rat
ionof1gofmet
hyl
predni
sol
onef
or5day
s
f
oll
owedby60mgoffpr
edni
sonei
sremar
kabl
e.160-
165Amor
erecentpat
ientexampl
e
st
ressedapr
omptr
esponsewi
thpl
asmaexchangeaf
teranunsat
isf
act
oryr
esul
twi
th
i
ntr
avenousi
mmunogl
obul
i
norcor
ti
cost
eroi
ds,
166

My
xedemaComa

Theencephal
opat
hyofhy
pot
hyr
oidi
sm canbeexpect
edi
npat
ient
swi
thpr
evi
ousl
ytr
eat
ed
t
hyr
oiddi
seasebutmayal
sodev
elopf
rom new-
onsetaut
oimmunet
hyr
oidi
ti
s.Ot
heri
mpor
tant
t
ri
gger
sar
ebact
eri
ali
nfect
ions,
trauma,
andr
ecentt
hyr
oidsur
ger
y.Anest
hesi
a,bar
bit
urat
es,
phenot
hiazi
nes,
and,
inpar
ti
cul
ar,
imi
prami
nemayr
esul
tinexacer
bat
ionofmy
xedema.7
Exposur
etocol
disawel
l
-recogni
zedt
ri
gger
,andoneshoul
dbeal
ertf
orat
hyr
oiddi
sor
deri
n
com m at
osepat
ient
sdur
ingt
hewi
nterseason.

I
npat
ient
swi
thmy
xedemacoma,
thecl
i
nical
char
act
eri
sti
csar
ethoseofmet
abol
i
cen
cephal
opat
hy,
wit
hsei
zur
esandmul
ti
focal
myocl
onus.Tappi
ngofmuscl
esf
requent
lyl
eav
esa
t
ransi
entl
ocal
swel
l
ingt
hatr
esem bl
esmy
otoni
a.Tendonr
efl
exesar
edi
mini
shedandmay
hav
eapr
olongedr
ecov
eryphase.Thet
ypi
cal
feat
uresofhy
pot
hyr
oidi
sm i
npat
ient
swi
th
my
xedemacomaar
eusual
l
ypr
esent
:dr
y,r
oughski
nandy
ell
owdi
scol
orat
ion,
puf
fyf
aceand
ey
eli
ds(
Plat
es8-
1and8-
2),
andl
ossofout
erey
ebr
ows.

Mostpat
ient
shy
pov
ent
il
ateandar
ecy
anot
ic,
168Hy
pot
her
miaandbr
ady
car
diamayal
sobe
t
hepr
edomi
nantf
indi
ngs.

I
tisi
mpor
tantt
orecogni
zet
hatassoci
atedmet
abol
i
cfact
ors,
suchashy
pogl
ycemi
a,
hy
ponat
remi
a,andhy
per
cal
cemi
a,maycausecoma.
 Aggr
essi
vet
reat
mentofmy
xedemai
ncl
udesmechani
cal
vent
il
ati
on,
flui
dresusci
tat
ion
i
npat
ient
swi
thhy
pot
ensi
on,
andparent
eral
admi
nist
rat
ionoft
hyr
oxi
ne(
500μg,
int
rav
enous
push)
.169Addi
son'
sdi
seasemaycoexi
st;
ther
efor
e,manypat
ient
sneedaddi
ti
onal
hy
drocor
ti
sone(
100mgi
ntr
avenousl
y).Conv
ersel
y,hy
pot
hyr
oidi
sm i
snotuncommoni
n
Addi
son'
sdi
sease,
andaf
tercor
ti
cost
eroi
dther
apy
,abnor
mal
resul
tsoft
het
hyr
oid-
sti
mul
ati
ng
hor
monet
estmaynor
mal
i
ze.

Hy
pot
her
miausual
l
yrespondsr
api
dlyt
ocor
rect
ionoft
hyr
oxi
neandt
ri
iodot
hyr
oni
ne
l
evel
s.Excepti
npat
ient
swi
thsev
erehy
pot
her
mia,
addi
ti
onal
suppor
tot
hert
hanbl
anket
sisnot
necessar
y.Heat
ingbl
anket
s,howev
er,
maywor
senshock.

Out
comeofmy
xedemacomacanbegood.Hy
landerandRosenqv
ist
oanal
yzedf
act
ors
associ
atedwi
thf
atal
out
comeandconcl
udedt
hatol
dage,
ini
ti
alhy
pot
her
mia,
shock,
and
excessi
vehor
monedosesoft
rii
odot
hyr
oni
net
ocor
recthy
pot
hyr
oidst
ate

pr
edi
ctedpoorout
come.

Adr
enal
Cri
sis

Acut
eadr
enal
insuf
fi
ciency(
Addi
son'
sdi
sease)i
sapot
ent
ial
probl
em i
nanyI
CU.Adr
enal
cri
sis
t
ypi
cal
l
yoccur
sinpat
ient
spr
evi
ousl
ytr
eat
edwi
thcor
ti
cost
eroi
dsi
nwhom t
hedosewasnot
i
ncr
easeddur
ingi
nter
val
sofst
ress.Sepsi
s,r
ecentmaj
orsurger
y,oruseofdr
ugst
hati
nter
fer
e
wi
thhepat
icbi
osy
nthesi
sorwi
tht
heper
ipher
alact
ionofcor
ti
cost
eroi
ds(
forexampl
e,ke
t
oconazol
e,bar
bit
urat
es,
pheny
toi
n,spi
ronol
act
one)maypr
edi
sposepat
ient
stoAddi
son'
s
di
sease.

Addi
son'
sdi
seasei
smani
fest
edbyr
api
dlyev
olv
ingshockanddehy
drat
ion.Labor
ator
y
di
agnosi
srev
eal
sapl
asmacor
ti
sol
val
ueof<15μg/
L,butt
het
ri
adofhy
ponat
remi
a,
hy
per
gly
cemi
a,andhy
per
kal
emi
aisal
sosuppor
ti
ve.Manypat
ient
scompl
ainofmi
grat
ory
my
algi
asandweakness,
andf
lexi
onpseudocont
ract
uresoft
hekneesandhi
psar
eof
ten
pr
esent
.Pai
nmayoccuri
nanyweakmuscl
e,butt
het
highmuscl
esar
epart
icul
arl
ytender
.
Cr
eat
ineki
naseconcent
rat
ionmayr
eachext
remel
yhi
ghv
aluesanddecr
easeaf
tersubst
it
uti
on.
El
ect
romy
ogr
aphi
c,exami
nat
ionofaf
fect
edmuscl
esmayshowmy
opat
hicf
eat
ureswi
thshor
t
dur
ati
onaul
dlow-
ampl
i
tudepot
ent
ial
s.

Al
ter
nat
ivel
y,weaknessi
nanaddi
soni
ancr
isi
smaybeassoci
atedwi
thhy
per
kal
emi
c
my
opat
hywi
thf
lacci
dtet
rapl
egi
aor
,inexcept
ional
cases,
wit
haGui
l
lai
n-Bar
ré-
li
kesy
ndr
ome,
12-
174Thecl
i
nical
feat
uresofAddi
son'
sdi
seasear
eli
stedi
nTabl
e8-
19,
175
Hy
per
pigment
ati
oni
nscar
s,i
nmucousmembr
anes,
andal
ongt
hegi
ngi
val
mar
gini
sal
eadi
ng
si
gnbutmaynotbepr
esent
.

Theencephal
opat
hyofadr
enal
insuf
fici
encymayhav
efeat
uresofpr
ofoundpercept
ual
i
mpai
rment
,wi
thl
ethar
gypr
ogr
essi
ngt
ocoma.Bi
l
ater
alpapi
l
ledemahasbeendescr
ibedbut
onl
yinassoci
ati
onwi
thpat
hol
ogi
cal
l
ydemonst
rat
edcer
ebr
aledema.Cer
ebr
aledemahas
beenr
epor
tedasapr
esenti
ngf
eat
ureofAddi
son'
sdi
sease.176I
npat
ient
swi
thsev
ere
el
ect
rol
yteabnor
mal
i
tiesandpr
ofoundhy
pot
ensi
on,
"encephal
opat
hieaddi
soni
enne,
ater
m
i
ntr
oducedbyKl
i
ppel
in1899,
maybedi
ff
icul
ttodi
agnose.

Subst
it
uti
onofcor
ti
sol
bycor
ti
cost
eroi
ds(
forexampl
e,hy
drocor
ti
sone,
300mg/
day
i
ntr
avenousl
y)andr
epl
acementofsodi
um andwat
erdef
ici
tandel
ect
rol
ytesar
ethemai
nst
ays
oft
reat
ingt
headdi
soni
ancr
isi
s.Out
comei
nmostpat
ient
sisgoodi
ftheunder
lyi
ngcausei
s
r
ecogni
zedandappr
opr
iat
elyt
reat
ed.

CONCLUSI
ONS

Rat
hert
hanannoyt
hei
ntensi
vecar
especi
ali
stwi
tht
ermssuchas"
mul
ti
fact
ori
al"and"
toxi
c-
met
abol
i
c,consul
tedneur
ologi
stsmusthav
eacl
eari
deaofhoweachoft
hev
ari
ous
di
stur
bancesmaypr
oduceanef
fectont
hener
voussy
stem.

Thecor
rel
ati
onbet
weenneur
ologi
cfeat
uresandaci
d-baseder
angement
sorsev
ere
el
ect
rol
ytedi
sor
der
sisbasedont
hef
ir
st,
rapi
dsi
gnofr
ecov
erywhent
heabnor
mal
i
tyi
sbei
ng
cor
rect
ed.El
ect
rol
yteabnor
mal
i
tiesar
epr
eval
enti
ncr
it
ical
il
lness.I
npr
inci
ple,
topr
oduce
neur
ologi
csy
mpt
oms,
elect
rol
yteabnor
mal
i
tieshav
etobesev
ere,
wit
hsubst
ant
ial
dev
iat
ion
f
rom nor
mal
val
uesbutoft
enal
sowi
thashi
fti
nav
eryshor
tti
mespan.Howev
er,
pat
ient
scan
r
emai
nasy
mpt
omat
ic.

Themostcommonhospi
tal
-andI
CUassoci
atedel
ect
rol
yteabnor
mal
i
tyi
shy
po
nat
remi
a.Causesi
nthepost
oper
ati
veper
iod,
inwhi
chhy
ponat
remi
aisf
requent
,ar
emor
phi
ne
uset
hatl
eadst
ovomi
ti
ngi
nsuscept
ibl
epat
ient
s,wat
err
etent
ion,
andl
i
ber
aluseoff
lui
ds
of
tengi
vent
oov
ercomepost
oper
ati
veol
i
gur
ia.Sev
ere,
unr
ecogni
zedhy
ponat
remi
amaycause
sei
zur
es,
respi
rat
oryar
rest
,andv
eget
ati
vest
ateorpr
ogr
essi
ont
obr
aindeat
h,par
ti
cul
arl
yin
y
oungwomen.Thecondi
ti
oni
sfor
tunat
elyext
remel
yrar
e.I
nmanyot
herpat
ient
s,asi
ngl
e
sei
zur
eordecr
easei
nlev
elofconsci
ousnessi
sseen.Al
thoughconsi
der
abl
edebat
ehas
cent
eredont
hespeedofcorr
ect
ion,
andsomei
nvest
igat
orsi
nsi
stt
hatThei
ssuei
scur
rent
ly
unr
esol
ved,
manybel
i
evet
hatcor
rect
ionofsev
erehy
ponat
remi
ashoul
dbecar
eful
l
y
or
chest
rat
edandgr
adual
topr
eventdemy
eli
nat
ion.Ani
mpor
tantpr
act
ical
consi
der
ati
oni
sthat
ov
ercor
rect
iont
oval
uesabov
e140mEq/
Lmaybeacont
ri
but
orycauseofcent
ral
pont
inemy
eli
nol
ysi
s.Onegui
del
i
nei
stocor
rectt
hepl
asmasodi
um concent
rat
iont
oav
alueabov
e125
mmol
/Lwi
th3%hy
per
toni
csal
i
neadmi
nist
eredat0.
5ml
/kgperhourOt
herel
ect
rol
yte
abnor
mal
i
ties(
pot
assi
um,
phosphat
e,cal
cium,
andmagnesi
um)pr
oducel
i
mbweakness,
di
aphr
agm weakness(
hypophosphat
emi
aal
one)
,tet
ani
ccr
amps,
oroccasi
onal
toni
c-cl
oni
c
sei
zur
es.

Endocr
inecr
isesar
eof
tenper
plexi
ngnotonl
yint
hei
nit
ial
present
ati
onbutal
soi
nthe
neur
ologi
csequel
aeofbi
ochemi
cal
corr
ect
ion.I
frecogni
ti
oni
sdel
ayed,
hypergl
ycemi
cor
hy
pogl
ycemi
ccomamaycausesev
erecogni
ti
vedef
ect
s.Cer
ebr
aledemaaft
ert
reat
mentof
di
abet
icket
oaci
dosi
s,mostof
teni
nchi
l
drenandy
oungadui
ts,
isaf
atal
compl
i
cat
ion.
Aggr
essi
vemanagementofcer
ebr
aledemawi
thconv
ent
ional
ther
apymaysav
eanoccasi
onal
pat
ientbutof
tenatt
heexpenseofper
sist
entdi
sabi
l
ity
.Hy
pot
hyr
oidcomaort
hyr
oidst
orm can
besuspect
edbychangesi
nski
ncol
orandhear
trat
eand,
inpat
ient
swi
thhy
per
thy
roi
dism.by
pr
opt
osi
sandconj
unct
ional
inj
ect
ion.Hashi
mot
o'st
hyr
oidi
ti
smaybeconsi
der
edi
nunexpl
ained
psy
chi
atr
icbehav
ior
,leukoencephal
opat
hy,
andi
ncr
easedant
ibodyt
it
ers,
butt
hedi
sor
deri
s
r
areandv
erydi
ff
icul
ttodi
agnose.Addi
son'
sdi
seasemaycauseweakness,
butt
hel
abor
ator
y
f
eat
uresofhy
ponat
remi
a,hy
per
gly
cemi
a,andhy
perkal
emi
aar
eusual
l
ydet
ect
edandcor
rect
ed
i
ntheI
CUbef
orepr
ogr
essi
ont
omar
kedencephal
opat
hyandcoma.