A 4-year-old with acute diarrhea develops hyponatremic dehydration: Na 118 mEq/L, serum osmolality 248 mOsm/kg, and is now seizing. The correct management of symptomatic severe hyponatremia in this child is:

• A 0.9% NaCl at 2x maintenance to correct sodium over 24 hours
• B Free water restriction and oral salt tablets
• C Sodium correction at rate of 12 mEq/L per 24 hours with 0.9% NaCl
• D 3% NaCl 1-2 mL/kg IV bolus over 10-15 minutes, repeat if seizing persists ✓

Explanation

Symptomatic severe hyponatremia (seizures, altered consciousness) is a neurological emergency. The immediate goal is to raise serum sodium by 4-6 mEq/L rapidly using hypertonic (3%) saline 1-2 mL/kg IV over 10-15 minutes to stop seizures — this can be repeated once if seizures persist. After seizure cessation, sodium correction should proceed slowly (no faster than 10-12 mEq/L per 24 hours or 0.5 mEq/L/hr) to avoid osmotic demyelination syndrome. Free water restriction is for euvolemic/hypervolemic hyponatremia, not hypovolemic dehydration. Isotonic saline alone would correct too slowly during active seizures.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.