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  1. Please watch this short video first: http://ca.news.yahoo.com/video/us-22424932/girl-dies-after-being-forced-to-run-for-hours-28404352.html The horrific aspects of this case can not be understated. My heart goes out to this poor little girl. However, I think it might be useful to consider this in the context of how susceptible pediatric populations can be to electrolyte derangement and dehydration. Hyponatremia occurs when serum sodium levels fall below 136 mEq/L however, children have been shown to suffer hyponatremia at levels higher than adults. I should mention that last line comes from something I scrawled in my notes a long time ago and I haven't the foggiest idea where I copied it from. If I find the article I'll post the link. According to http://emedicine.medscape.com/article/767624-overview, Hyponatremia occurs through several different types of pathologies, hypovolemic, euvolemic, hypervolemic, redistributive, and pseudohyponatremia. In this case I believe the pathology would be hypovolemic hyponatremia. The little girl had lost so much fluid, probably through sweating, that she dropped to dangerous levels of sodium. In addition to being susceptible to hyponatremia, children are also very susceptible to hypovolemia due to the lower amount of circulating fluids. If we go by the formula 80-85 ml/kg for circulating volume vs. weight, a 75 kg man will have around 6 liters of circulating fluid while an average 9 year old girl with a weight of 28 kg will have around 2.5 liters. That means an adult can lose up to 1.5 liters of fluid before entering into Stage III hemmorhagic shock, while a child can only lose .0625 liters of fluid before doing the same. Its also been shown that children can lose up 25% of circulating fluid before showing any signs of hypotension, so by the time a child's blood pressure actually begins to fall, it may be the beginning of the end. I once told by a clinician that when you sweat, you are in essence, bleeding, and should be approached the same way for fluid replacement. Whether that's 100% true or not, I'm not exactly sure, but sweating can definitely be a significant source of hypovolemia in all populations. Euvolemic hypovolemia can occur if total body water is increased while sodium levels remain the same. This, I reckon, would apply to someone who has been sweating for a long period while only drinking water. Symptoms of hyponatremia include ALOC and seizure activity. The literature I have read cautions against trying to balance out hyponatremia with a hypertonic sodium solution. If nothing else I think that when presented with a child suffering ALOC or seizures with an accompanying environmental factors should be treated with a high level suspicion for hyponatremia. Does anyone think there is a preferable isotonic crystalloid to be used in this type of situation?
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