I got this through our club mailing list. It's pretty long but worth the read if you're an endurance rider.
>>>
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, 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 and 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 anti-psychotic 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 its Vermont".. 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 sodium 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.
<<<
>>>
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, 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 and 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 anti-psychotic 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 its Vermont".. 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 sodium 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.
<<<
neaky: