Mt. Whitney Portal Store & Hostel Forums General Mt. Whitney Portal Store Message Board Hypontremia/ too much water

After reading Spankybobs post about a hiker who was in a coma after coming down with this, I thought it important to define it.

Hyponatremia

Hyponatremia is a condition known as "water intoxication." It is the opposite of dehydration, and is often associated with long distance events like running and cycling. Moreover, it’s not an unusual problem, and you can develop it in a few hours.
As you consume large amounts of water over the course of a day, blood plasma (the liquid part of blood) increases thereby diluting the salt content of the blood. At the same time, your body also loses salt by sweating. Consequently, the amount of electrolytes available to your body tissues decreases over time to a point where that loss interferes with brain, heart, and muscle function! You have to replace these electrolytes! They're essential to the normal electro-chemical operation of your nervous system.


Symptoms
Though the condition is opposite to dehydration, the symptoms generally mirror those of dehydration (apathy, confusion, nausea, and fatigue), although some individuals show no symptoms at all.

If untreated, hyponatremia can lead to coma and even death.


Prevention
The World Health Organization advises the best combination of electrolytes mixed in 1 liter of water (one typical-sized Nalgene™ water bottle) is as follows:

20.0g Glucose

3.5g Sodium Chloride

2.9g Trisodium Citrate

1.5g Potassium Chloride



Drink the RIGHT fluids! If you can't mix your own solution of the above formula (or don't care for its taste), Pedialyteâ (or the generic equivalent) is a great source and its readily available at any market or pharmacy in a variety of flavors. As a drawback, it is a little expensive. As a cheaper alternative, some sports drinks are a fair source of replacement electrolytes -- though they tend to have excess sugar for that quick energy burst. Look for brands such as Gatorade™ that try to match the body's natural levels of potassium, citrate and sodium chloride.

If you have to watch your sodium or glucose intake, consider taking sodium- and glucose-free electrolyte tablets called Electrol. This is perhaps the least expensive option of all, but make sure you drink enough fresh water.

Copied from a web page. www.geo-outdoors.info

The word you were looking for is HYPERnatremia, but the point was well made.

highsierra had it right--it's hyponatremia. Hypo = low, natremia = sodium. It's the natural consequence of too much water combined with loss of sodium and other electrolytes.

I've not heard of hypernatremia in mountaineering. The place where I've heard this reported, and even then only very rarely, is in ultramarathons, triathalons, etc. The cause is drinking huge quantities of water while simultaneously sweating out large amounts of salt. That is relatively easier to do when you are running/riding in a race on a hot day where there are water stops along the route. It is very hard (impossible?) to do on a cold mountain when drinking a liter an hour. My understanding is that you have to consume tens of gallons of water while sweating profusely to suffer from hypernatremia. It would be very difficult to do that on a big mountain.

Sierra Sam, I thought so too, it also occurs a lot in the Grand Canyon, but SpankyBob reported of a woman that was rescued on Mt. Whitney on 9/20 who was recovering from this condition. So I guess it can happen on a big Mtn.

The conditions leading to and symptoms have been pretty much described but here is my question for one of the qualified individuals who frequent this board (qualified as in MD's and not someone who read Runner's World a few issues ago). What sort of first aid response would be best if one encountered an individual exhibiting these symtoms in a back country environment?

That would be the July issue of Runners World. It focuses more on prevention rather than treatment, but a very informative article.

Found this on a web MD site. Seems to be the general concensus that severe Hyponatremia cannot be treated in the backcountry besides the obviuos, ceasing of water intake.
"Treatment
Minor symptoms, such as nausea and mild muscle cramps, can be treated by eating salty foods and hydrating with a sodium containing sports drink. More severe symptoms require treatment by qualified medical personnel. If you think you are suffering from hyponatremia or are unsure, seek medical attention immediately."

For me this also raises the issue of people attempting to "fully hydrate" before starting their hike by drinking 2-3 liters of water at once. This is a total waste of water because your body cannot absorb it that quickly. You'll just pee most of it out. My understanding is that the average-size body can't absorb more than about 2 liters of water per hour.

Hyponatremia is actually the most common electrolyte disorder seen with hospitalized patients. In addition to extreme exercise and altered water/sodium intake many medical conditions and medications can cause hyponatremia. One common medication is any diuretic. It would be interesting to know if this individual had taken Diamox. Any pulmonary condition can also increase risk. This would include Asthma.

Acute (developing over 24-28 hour time period) hyponatremia leads to brain swelling thus the symptoms of changing mental status and seizures. A common cause of death is severe brain swelling leading to herniation of the brain stem. Due to it's morbidity it is definitely a medical emergency.

It is true that hyponatremia does occur with excess "free water" intake. This occurs when excess amounts of water intake are not balanced with proper electrolytes. It can and often does also occur with low water intake with excursion. This would be related to excess loss of electrolytes through sweating. In either case some sort of electrolyte replacement is in order and if it is determined the person has been drinking excessive amounts of water, stop free water intake.

Finally, this person needs to be seen in the hospital.

Dr. Tim Noakes, who is a notable author and researcher of running related issues has a little report on hyponatraemic encephalopathy at
http://www.ultramarathonworld.com/news_2003/n26jy03a.htm
There is also a link to another related article from this site that might be of interest.

high sierra-

I am very doubtful that was the real diagnosis of the 9/20 case on Whitney. Unless they ran a blood electrolyte test, which cannot be done on the mountain, they are just guessing that was the real condition. I will ask some of my high altitude medical buddies if they have ever seen a real case of hyponatremia in the climbing world. The Grand Canyon is more believable to me, it fits the profile of hot, long and tons of water available.

As to the the appropriate first aid , there isn't much that you can do on the mountain other than give them some electrolytes to drink. Best thing is to get them to a hospital/ambulance where they can administer IV 'lytes.

ss

The problem with treating this condition in the wild, is that the symptoms are the same as seen in many other, often much more common, problems.
For example, the things mentioned above, nausea and muscle cramps, are *much* more common with dehydration.

There is a tendency for there to be an "electrolyes bandwagon", which I'd define as thinking of electrolyte replacement as a cure all. I'd caution the reader to be careful, as I'm not sure that there is yet any clinical data that electrolye solutions protect against hyponatremia at all, although it is logical that they might. In reality, all the solutions are VERY dilute. To get a sense of normal sodium concentration in body fluids, it is about the same as seawater.

The primary issue is fluid quantity, in all the cases that I have read about, in which the affected athlete had consumed prodigious amounts of fluids.

How do these threads get so long before someone that knows what they're talking about gets in on the action?

Yes its hyponatremia, not hypernatremia.

Yes its quite possible for a Mt. Whitney climber to get this condition. Yes it would be quite rare for someone to be able to consume enough water on the mountain to get this condition without following the advice occasionally given on this website to drink prodigious amounts of fluid, "overhydrate," "prehydrate," and the like.

This:
"For me this also raises the issue of people attempting to "fully hydrate" before starting their hike by drinking 2-3 liters of water at once. This is a total waste of water because your body cannot absorb it that quickly. You'll just pee most of it out. My understanding is that the average-size body can't absorb more than about 2 liters of water per hour."

is a bunch of crap. Your body can absorb it, in fact it must absorb it unless you're ****ting it out. The fluid goes from your small intestine, into the blood stream, through the kidneys, down to the bladder, and out the hole. To be peed out, it must in fact be absorbed. It may be true that the body cannot absorb more than 2-4 liters of water per hour, but the excess sits in the stomach until there is no more space and then it is vomited.

Another quote:
"There is a tendency for there to be an "electrolyes bandwagon", which I'd define as thinking of electrolyte replacement as a cure all. I'd caution the reader to be careful, as I'm not sure that there is yet any clinical data that electrolye solutions protect against hyponatremia at all, although it is logical that they might. In reality, all the solutions are VERY dilute. To get a sense of normal sodium concentration in body fluids, it is about the same as seawater.
The primary issue is fluid quantity, in all the cases that I have read about, in which the affected athlete had consumed prodigious amounts of fluids."
...AMEN.

"Hyponatremia is actually the most common electrolyte disorder seen with hospitalized patients." TRUE

"In addition to extreme exercise and altered water/sodium intake many medical conditions and medications can cause hyponatremia." TRUE

"One common medication is any diuretic." NOT TRUE

Lasix for instance generally doesn't cause hyponatremia, but rather low potassium and calcium. HCTZ, however, another common diuretic frequently will cause hyponatremia as well as low potassium and high calcium.

For the curious, Diamox generally doesn't cause electrolyte imbalances. (Dehydration yes. Tingling yes. Overconfidence to ascend when one should be descending yes.)

Now, as I recall the original question had something to do with wilderness treatment. I submit the difficult question is wilderness diagnosis. Sure the symptoms mentioned above are consistent with hyponatremia (apathy, confusion, nausea, and fatigue,) but they are also consistent with a hundred other diseases. The condition is diagnosed with lab test performed on blood. Anyone got a lab on Mt. Whitney? Even a paramedic with access to 3% saline (the "cure") would be extremely foolish to administer it to a patient without knowing the serum sodium level to begin with. Correcting the sodium too quickly is very risky. So, if by some crazy way it was obvious that it was hyponatremia, the only option available to the astute wilderness first responder would be the one generally done in hospitals, water restriction as well as rapid transport to a medical facility.

This:

"Drink the RIGHT fluids! If you can't mix your own solution of the above formula (or don't care for its taste), Pedialyteâ (or the generic equivalent) is a great source and its readily available at any market or pharmacy in a variety of flavors. As a drawback, it is a little expensive. As a cheaper alternative, some sports drinks are a fair source of replacement electrolytes -- though they tend to have excess sugar for that quick energy burst. Look for brands such as Gatorade™ that try to match the body's natural levels of potassium, citrate and sodium chloride."

...sounds like a sports drink advertisement. Yes, sports drinks have their place. Yes, you can drink nothing but gatorade all the way up Mt. Whitney. But the average healthy young person can also drink water all the way up and be fine. Avoid the fanatical water notions like "overhydration" and "prehydration" and you'll be fine. Once you are peeing clear, you've had plenty to drink. You can start drinking a little slower then. Prehydration should be on the order of a cup or two, not 2-4 liters. May we all climb happy and not have hyponatremia until we are old and overmedicated. Remember, the dumbest kidney is smarter than the smartest doctor. They'll balance your lytes for you if you treat them well.

Desperado M.D.

The hiker that I saw on September 20 was being accompanied by two rangers and another hiker. I was in her presence for only a minute or two as I asked the rangers if there was anything I could do to help. In the relatively short time I saw her I noticed the following symptoms on her: she looked ill and had lost color in her face, she was barely coherent, she could barely walk without assistance and was staggering, and when the rangers asked her to walk with them down the mountain she immediately turned and headed uphill. Since the rangers told me everything was undercontrol and a helicopter was on the way I proceeded onto trail camp. The rangers told my buddy who was hiking a few minutes behind me on the trail that they thought she was in insulin shock. The rangers were very concerned about her condition and that is why they got the helicopter up to her so quickly.

I am not a medical expert. My first impression was that she was drunk. I had not heard of water intoxication until yesterday when I heard from a firend of a friend that she had spent a few days in the Bishop hospital in a coma.

The weather that day was sunny, but mild. I do not know anything about her past medical condition, training, or how much water she was drinking. I mentioned all of this to a doctor friend of mine and he said that it is possible she was predisposed to such a condition or that the altitude may have been a contributing factor. However he also admitted that this was not a condition that he was too familiar with other than cases he sees related to hospital stays.

I would give it about 1 million to 1 odds that it was not hyponatremia. The symptoms that you describe could be a wide range of things and hyponatremia is so rare at all, let alone in mountaineering, that there are hundreds of possibilities that are far more likely. It is also more dangerous for people to start making home brew electrolyte solutions to drink on the mountain than the risks of hyponatremia on Whitney.

Given the relative reliability of my sources I would think about taking up your odds of a million to one if I was a betting man, however, I agree that it does seem pretty unusual and I will see if I can get more information.

It appears I jumped the gun with my faulty etymology on hypernatremia/hyponatremia and I stand corrected. I was indeed full of grizzly scat!!

Thanks for the good advice Desperado MD. In 5 summits of Whitney and one of White Mountain Peak, I've usually consumed between 2-3 liters of water and probably 1,000 calories of well balanced snacks during the entire round trip. I tend to drink and eat small amounts frequently with very short stops every hour to hour and a half. My pace usually puts me on the summit from the portal store in 6-7 hours. While I usually wear hiking shorts and a zip tee with good boots, good sun glasses and a hat, I also carry light rain pants, a fleece vest, a light rain/wind jacket, and a ski cap and a change of socks and a first aid kit plus the food and 4 liters of water. This combination of gear and weight seems to work well for the July through mid September hikes. Rick