A patient with hyponatremia presents with confusion and seizures. What is the priority management?

• A. Seizure precautions and rapid correction with hypertonic saline if indicated, with careful monitoring
• B. Immediate diuresis
• C. Isotonic saline bolus only
• D. Do nothing

Answer: (A)

When hyponatremia presents with confusion and seizures, the situation is an emergency and the priority is to protect the patient and rapidly correct the sodium safely. Begin seizure precautions to prevent injury during possible seizures, and administer hypertonic saline (typically 3% NaCl) to raise the serum sodium quickly enough to relieve cerebral edema and neurologic symptoms. A common approach is a small hypertonic saline bolus (for example, 100 mL of 3% NaCl over 10 minutes), which can be repeated if symptoms persist, with close monitoring.

The goal is to increase serum sodium by about 4–6 mEq/L promptly, then slow the rate of correction to avoid overshoot and the risk of osmotic demyelination syndrome. Monitor neuro status and serum sodium every 2–4 hours, along with fluid status and signs of volume overload or electrolyte shifts.

Other options are not appropriate as initial management in this scenario: diuresis does not address the acute neurologic symptoms and can worsen sodium balance; isotonic saline bolus may not correct the hyponatremia quickly enough and can be inappropriate depending on the underlying cause; and doing nothing ignores a life-threatening emergency.