Immediate Questions

A. What are the vital signs? Most children with hypernatremia are dehydrated, with typical signs and symptoms that are dependent on the degree of dehydration.

1. Mild dehydration (3% in older children; 5% in infants). Pulse may be normal or increased, urine output is decreased, and physical exam is generally normal.

2. Moderate dehydration (6% in older children; 10% in infants). Produces tachycardia and little or no urine output. On physical exam, eyeballs and fontanelle are sunken, with decreased tears, dry mucous membranes, loss of skin turgor, delayed capillary refill, and cool skin.

3. Severe dehydration (9% in older children; 15% in infants). Pulse is rapid and weak, BP is decreased, there is no urine output, and on physical exam, there is accentuation of findings noted in moderate dehydration, in addition to notable skin mottling.

B. What is patient's neurologic status? Hypernatremia, even in the absence of dehydration, causes CNS symptoms that tend to parallel the degree of elevation and rate of increase in the serum sodium concentration. Patients are irritable, restless, weak, and lethargic. Some infants have a high-pitched cry. Older children complain of extreme thirst and nausea. These patients are at risk of developing brain hemorrhage (subarachnoid, subdural, and parenchymal). The etiology of the hemorrhages is related to shifting of water from the intracellular space as extracellular osmolality increases. This shift decreases brain volume, resulting in tearing of intracellular veins and bridging blood vessels as the brain moves away from the skull and meninges. Seizures and coma may ensue.

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