Rapid correction of severe acute hypernatremia caused by soy sauce ingestion
June 13, 2013, 12:47 pm
Survival of Acute Hypernatremia Due to Massive Soy Sauce Ingestion. Carlberg DJ et al. J Emerg Med 2013 Jun1 [Epub ahead of print]
This fascinating case report from the University of Virginia Medical Center describes a 19-year-old male who — apparently on a dare — ingested a quart of soy sauce (17-18% sodium chloride).
When brought to the emergency department 2 hours later he unresponsive (GCS = 3) and had possible seizure activity. His pulse rate was 147 bpm. Head CT was unremarkable. Labs were significant for a sodium of 177 mmol/L and glucose of 384 mg/dL. Four-and-a-half hours after ingestion his sodium was 191 mmol/L.
At that point, the treating physicians reasoned that since a sodium level this high has been strongly associated with fatality and the development of hypernatremia in this case was quite rapid, it would be reasonable to correct the electrolyte abnormality quickly.
The patient received 6 liters of 5% dextrose (D5W) over 30 minutes, followed by free water at a slower rate. His mental status gradually improved, and 32 hours after ingestion his sodium level was 145 mmol/L. At follow-up one month after the admission his mental status was reported as normal and he was “performing well on college examinations.”
The authors state that, to their knowledge, the corrected sodium level of 196 mmol/L is the highest ever reported from acute salt ingestion in a patient who survived.
Chronic hypernatremia should be corrected slowly, since the brain adapts over time to a high sodium level by producing idiogenic osmoles. In this situation, reversing hypernatremia too rapidly can cause cerebral edema, seizures, or herniation. In the case reported here, the sodium level increased so acutely there was no time for this adaptive mechanism to occur.
There are many videos on YouTube of adolescents and young adults taking the so-called “soy sauce challenge.” This seems even less wise than enduring the “cinnamon challenge,” which TPR has reported on before.
Tip o’ the hat to @ToxTalk, who alerted me to this article.