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RE: [RC] Long but interesting post on Hyponatremia - Ramspott.Kathy

Would drinking sports drinks in conjunction with water make any noticeable 
difference?  I don't know if gatorade contains sodium.

Kathy R




-----Original Message-----
From: William Rice [mailto:WER@xxxxxxxxxxx]
Sent: Thursday, September 18, 2003 2:27 PM
To: ridecamp@xxxxxxxxxxxxx
Subject: [RC] Long but interesting post on Hyponatremia


All,
With all the posts about hyponatremia I thought maybe you would like to read
an account of an actual case--it is scary and Michele continues her struggle
please delete if not interested but it does give us all an insight.  Of course
all the endurance riders I have watched tend to under hydrate vs over
hydrating.  This comes from the ultralist BTW.
Bill In Maine

Hi everyone,

I'm writing this to "the big list", the PA Buzzards, Virginia Happy Trails
Running Club, the Montgomery County Road Running Club (in Maryland) and a
few others to say THANK YOU SO VERY MUCH for the Get Well Wishes, Cards,
Flowers, and overall concern and support.  Wow!  I have a lot of wonderful
friends!

I am writing to so many people for a few reasons - first, I have received
many inquires about how I am doing after the Vermont 100 miler.  Also, many
people heard about what happened (which I'll explain below) but only got
parts of the story. So you'll get the story here - as best I know it, from
me, Michele Burr - the person who got a severe case of hyponatremia at
VT100.  The people who do know about my getting hyponatremia have urged me
to post something so that people are aware of this very serious problem.

I must admit, I don't remember much because I had a seizure and went into a
coma but I have pieced together many things from people who saw me at the
end of the race and from talking with my husband, who thank God, was there
at the finish line and with me during my 5 day stay at two hospitals in
Vermont and then New Hampshire.

WHAT IS HYPONATREMIA?  This is a condition in which there is a very low
concentration of sodium in your blood. It is also seen in conjunction with
WEIGHT GAIN (not weight loss) and most often occurs during endurance
exercise lasting more than 5 to 7 hours. (From:
http://www.halcyon.com/gasman/water.htm)  More specifically, hyponatremia
develops as sodium and free water are lost and replaced by fluids, such as
plain tap water, half-normal saline, or dextrose in water.  Basically, this
condition occurs when a person takes in too much water and not enough salt.
So you are probably wondering...was I taking Suceed! caps? Was I drinking
electrolyte fluids?  Yes to both of these questions but obviously I was not
taking enough of either one of these things and yes, I was also eating
potato chips, peanut butter and jelly sandwiches, fig newtons, and potatoes
-but again, it wasn't enough salt and I was taking in too much water.  My
weight was up 5 pounds at the last weigh-in. To give you an understanding of
where my sodium level was compared to a normal person....most people have
about 140-145 mEq/L - this is some sort of measure of the amount of salt in
your blood.  I had 113 mEq/L.  This is extremely low.  So, why is this a
problem?  Because you need sodium in your blood for your brain to function.

WHAT ARE THE SYMPTOMS? The answer to this question is the scary part and why
this is such a medical emergency when it occurs.

****Many of the symptoms are NEUROLOGICAL in origin.**** Level of alertness
can range from agitation to a coma state.  Variable degrees of cognitive
impairment (eg, difficulty with short-term recall; loss of orientation to
person, place, or time; frank confusion or depression).  Other symptoms
include seizure activity and irrational behavior. In patients with acute
severe hyponatremia, signs of brainstem herniation, including coma; fixed,
unilateral, dilated pupil; decorticate or decerebrate posturing; and
respiratory arrest.  Coma and seizures usually occur only with acute
reduction of the serum sodium concentration to less than 120 mEq/L.
(Remember my sodium level was at 113 mEq/L.)

I didn't recognize where I was or who my friends were or who my husband was
at the end of the race.  I walked the last 5 to 10 miles which is very
unusual for me and people said I didn't know who they were and it appeared
as though I didn't even know I was in a race.  Shortly after I crossed the
finish line on Saturday night I started to vomit uncontrollably then I had a
seizure then I went into a coma. I remained in a coma for 3 days.  At some
point before I woke up out of the coma I began the "irrational behavior"
mentioned above.  I pulled out all my IVs and ripped off my EKG patches and
tried to kick and hit the nursing and neurosurgeon staff.  I was very
combative whenever someone tried to touch me and was eventually given
antipsychotic medication.  When I woke up I didn't know where I was, what
had happened, what month, or year it was. Upon being forced to give a guess
for the month I told the neurosurgeons, "I think it's Vermont" for the
month.  I couldn't read and I couldn't add numbers.  On Tuesday after the
race I started to feel much, much, better.  I could read again and I had
watched a car commercial to figure out what year it was.  I also got a lot
of the story about what happened from my husband.  It was on this day (or
maybe Monday?) I learned I had been in another hospital earlier.  Why was I
first in a small local hospital (Ascutney in Windsor, VT) and then
transferred by ambulance to Dartmouth-Hitchcock?  That has to do with the
scariness about how to treat this medical emergency.  It you don't do it
right, it will lead to further and permanent brain damage.

HOW IS HYPONATREMIA TREATED?  From http://www.rice.edu/~jenky/heat.html: It
says that the condition is frequently mis-diagnosed as dehydration and that
the consumption of water makes matters worse because it dilutes the blood
sodium concentration even further than it already is.

From http://www.emedicine.com/EMERG/topic275.htm :
"The principal causes of morbidity and death are when chronic hyponatremia
reaches levels of 110 mEq/L or less and cerebral pontine myelinolysis (an
unusual demyelination syndrome that occurs when HYPONATREMIA IS CORRECTED
TOO QUICKLY).

Much has been written about treatment of hyponatremia and the potential
adverse outcome of central pontine myelinolysis. This condition is
demyelination of the pons, which can lead to mutism, dysphasia, spastic
quadriparesis, pseudobulbar palsy, delirium, coma, and even death.
Raising the serum sodium concentration more than 25 mEq/L or to a normal or
above-normal level in the first 48 hours increases the likelihood of central
pontine myelinolysis.

The main controversy in the literature surrounds treatment of chronic
symptomatic hyponatremia because, as mentioned, central pontine myelinolysis
may result if the condition is corrected too rapidly. Therefore, although
treatment in these patients is similar to that just described, the rate of
correction should be slower (0.5 to 1 mEq/L per hour). Aggressive therapy
should be discontinued when the serum sodium concentration is raised 10% or
symptoms abate."

Upon being admitted at the first hospital in Vermont my soium level was 113
mEq/L but then quickly went to 116 and the next reading was at 126. The
hospital felt uncomfortable and kept telling my husband it was possible I'd
get "PONDS" - which is central pontine myelinolysis (permanent brain
damage).  They also told him to think about long term care for me and that
"things could turn out a number of ways".  They also asked him if I remained
in a vegetative state, would I want my organs donated and did I have a
living will prepared.  At this point, an ambulance took me to New Hampshire
to Dartmouth-Hitchcock.  Needless to say, I think I aged my husband about 10
years during these 5 days.

WHAT ARE THE LONG TERM EFFECTS?  Well, so far I feel I am about 95% back to
where I was neurologically before the race.  (Physically, I lost 10 pounds.)
I couldn't remember my password when I got to my office so I couldn't log
into my computer and I forgot a combination lock number I often used.  I
also forgot a few people's names.  I had a little bit of trouble typing and
signing my name but that seems to be gone now. The last clear things I
remember from the race are at the mile 18 aid station. I am also a bit
spacey (it's a bit difficult for me to concentrate) but I can drive.  I am a
research scientist so it's important that I be able to generate and
interpret statistics. I haven't tried that yet but I'm optimistic.  Here are
a few more links (in case you just can't get enough about hyponatremia):

http://www.spinalhealth.net/hyponatremia.html

http://www.fred.net/ultrunr/hyponatremia.html#Paul

Finally, the way to avoid this in the future (for me) is to drink less water
and eat more salt.  I will also push for a blood test from my doctor before
I run another 100 (this was my 5th one) to make sure I am not starting out
at a deficit - which is what the doctors were suggesting at
Dartmouth-Hitchcock Hospital.  They said that my low sodium diet, combined
with a high volume of running (sometimes as much as 100 miles/week) and
sweating in the heat and humidity here in the Washington DC area were the
problem combined with the low volume of electrolyte fluids (relative to the
amount of water I was taking in).

This was scary.  I hope some people will be educated by reading this and for
the many people who emailed and asked me what happened, I hope this answered
their questions.

Thank you so very much again everyone for your concern.  My friends,
co-workers, relatives, and the ultrarunning community have been great!

Michele Burr



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