KC is a 28 year old woman

presenting to the emergency room unconscious

her husband Josh tells the admitting nurse at admission that she had suffered at least two seizures in the past 30 minutes

You see Casey had been participating in a radio show

competition hold your wee

for a Wii

Where contestants would drink up to three gallons of water in two hours

and the last person to urinate or vomit would be the winner of a Shiny Nintendo Wii

Clearly this was for gags on behalf of the radio station and at the expense of it's contestants, but Casey was determined

She was going to win that nintendo and be able to play it with her kids

Immediately after finishing all three gallons of distilled water

casey complained of severe nausea and in order to hold back the urge to vomit

She was found to clench the armrest of her chair

Within 20 minutes

Casey was easily crowned victorious in the challenge and her husband began to drive her home about an hour after

Finishing all that water and in the car she begins to cry

she's suffering a massive headache and tells her husband

I'm coming out of my skull

She feels pressure push against her eyes and reports the division in her left eye

is going dark her husband drives quickly

So they can get home and she can take a nap because they both believe she can sleep it off

Interestingly enough after drinking all that water she has no urge to urinate or vomit,at home now

Casey goes to her bed to lay down while her husband begins to prepare dinner

Dinner's ready, it's only been 30 minutes and the husband watches some TV and lets his wife sleep

It's here in bed that Kaifi Silently suffers her first seizure

Unknowingly Josh Watches TV for another hour trying to be considerate to his wife who he believes is sleeping

But is actually unconscious and suffering seizures every 20 minutes as he finally feels

It's time to call her for dinner an hour later

He goes to her room to see her and finally sees her suffer yet, one more seizure

911 is called, inside the ambulance

Kc's sixth seizure is seen by the paramedics as she arrives to the emergency room where we are now

given the patient's immediate past medical history

There's several clues as to what's happening any doctor will be able to easily identify that KC is suffering from

acute

acute hyponatremia

hypo meaning low

natr meaning pertaining to sodium or more formally natrium as is shown by its symbol on the periodic table of elements

and emia meaning presence in blood

low sodium presence in Blood

acute meaning that there are no underlying pathophysiologic conditions

that are leading to this problem aside from the three gallons of water that are inside her body

At the Moment which leads to the first clue

Josh tells the admitting nurse that KC had not vomited or urinated

since the contest ended which means that there hasn't been a net flow out of her body

the three gallons of water are hanging around

somewhere inside of her that water is important to note because

KC is a woman the female body is on average made of about 50 percent water compared to male bodies

which are typically 60% water given that Kasey is 28 years old

she's premenopausal, meaning that she has more estrogen in her body than a 60 year old post menopausal woman

Estrogen is a sex hormone that increases the proliferation of fat tissue

fat, which is made up of oils doesn't mix well with water so as women's bodies are made of more fat

they hold on the less water compared to man

who produce more sex hormone called testosterone

which increases the production of muscle tissue a tissue that does hold on to water

So if the female body is typically made of less water and contains more fat which doesn't mix with water at all

then, where are those 3 gallons of water inside KC's body

well, there's a bit of basic chemistry to be known here the fluid in your body is a soup

of several chemicals in this case the most important being sodium which is one half of this table salt

The interesting thing about sodium is that it creates something called an osmotic gradient which means that wherever sodium is

Water will flow towards it in this small science experiment

I dissolve salt in this water and place it into a tube

I submerge the tube in a pool of water that has no salt dissolved in it

You'll see that water flows into the tube

that water flows towards the sodium

so let's go back to the name of KC's condition

Hyponatremia low sodium presence in blood

if she hasn't urinated or vomited

Since she drank all three gallons of water. How is it possible that there's low sodium?

Nothing has left her body. So there shouldn't be less sodium present, right?

yes, but the water in your body is made of

0.9% sodium so for every one liter of water there are 9 grams of sodium

most of the water in your body is inside your cells

and in general exists with 0.9% sodium

in medical world we call this normal saline or isotonic

KC drink distilled water which has no salt

if water flows to where there's salt and your body water which is mostly inside yourself has salt

then KC's cells must have lots of water flowing into them

This would mean that her organs like her liver

and her stomach are starting to swell with water

that should be ok though, because your abdomen is soft

but the water wouldn't just be flowing to those two it would be flowing into her heart, her muscles

but those aren't enclosed in a hard space either, so it wouldn't be too much of a problem if they swelled up inside

but what is a problem is the brain

It's enclosed inside a hard space your cranium also known as your skull

Your brain only has space to Expand

8% in volume until it starts to push up against the bones in your skull as the water keeps flowing

Into the sodium-Rich cells of KC's body her brain is starting to crush up against the size of her skull

Smashing blood vessels as it expands preventing blood flow in causing

hypoxia or the Deprivation of Oxygen

As the flow of blood is disrupted to KC's brain parts of it start to necrosis or quite literally die

This damaged upon brain expansion is known as herniation and means permanent brain damage

in KC's case. The disruption of hydrodynamic flow is a recurring physiologic theme when it comes to causes of Sudden death

a cocaine overdose can overstimulate the heart causing something called atrial fibrillation

This is a time when one part of your heart will beat at over 300 beats per minute not actually

Contracting or ejecting blood it causes blood to pool forming a clot which can lodge directly into your brain causing a stroke

blocking oxygen flow to your brain and killing the tissue in the case of a heart attack the blood vessels providing your heart with

Oxygen are blocked by a plaque meaning your heart muscle

No longer gets any oxygen, the muscle begins to die quickly and the rest of your body no longer

receives any blood in the case of alcoholism when the liver is cirrhosis or

99% damaged and scarred it prevents blood flow through the hepatic portal vein

Causing blood to back up into the veins of the stomach creating something known as varices and if those veins burst from the back up

You will bleed to death into your stomach

a rare genetic disorder known as Tuberous Sclerosis Complex

mutates every single cell in the body and can grow tumors in the brain called sub ependymal giant cell astrocytoma

this disrupts the flow in the brain and causes an enlargement of the head known as hydrocephalus as well as these

infantile spasms which are really a form of seizure and has severe consequences

on the development of these infants they may never become

functional adults if this isn't treated the notion of blood flow through vessels was studied in

1840 by a French physician named Jean Louie Marie Poiseuille

he discovered the physical law that more generally describes flow of a fluid through a cylinder whether that's blood through an artery

Water through a pipe or even electricity through a wire as much as you'd be upset by an unreliable

Internet connection disrupting the flow of data for the videos that you watch on the internet

the disruption of blood flow in KC's case has much more severe consequences

Unified under the same concept, her past medical history all point to this the headache

the pressure against her eyes and the words, "I'm coming out of my skull"

The darkening vision and her seizures since KC is still breathing, it may not yet be too late for her

she may not have herniated her brain just yet

the easiest way to treat her at this point is to use the same science that diagnosed her if water follows sodium and

water's flowing into her organs then the cure is to draw that water out of her organs with even saltier water

0.9 percent sodium is the standard in her body and the distilled water she drank is floating towards that gradient

then Infusing three percent sodium water back into her veins

will reverse the flow of that water back into her bloodstream and out of her organs

The final thing to note here is that KC's condition is incredibly, incredibly rare

the reason she suffered the acute hyponatremia is because of something called

SIADH

syndrome of inappropriate anti diuretic hormone

a diuretic is something that causes you to urinate

So an anti diuretic is something that prevents you from urinating

Do you remember that severe nausea she complained of after drinking all three gallons?

Well, nausea is a powerful stimulus for something called antidiuretic hormone

Formerly known as vasopressin

Since your body thinks it's going to lose a lot of fluid in vomiting

it releases a hormone telling your organs to hold on to the water that it already has

it wasn't appropriate in KC's case

and not only did she hold on to the water that was already inside of her before drinking the three gallons of water

But it also added the three gallons and wouldn't allow her to urinate and because in this context

SIADH is very rare. It was an accident that had happened to KC and not the other

contestants on the Radio show, but still it's never anything you should ever want to try

Luckily for KC no herniation occurred in her brain and the 3 percent sodium infusion was enough

to solve the hyponatremia and draw the water out of her brain upon regaining consciousness

urination preceded her saying hello to her husband

This case was originally presented at a grand rounds in Central, New Jersey

It's based off of a true story that had a much different ending

Originally modified to give residents and fellows a perspective on treating SIADH

acute and Chronic hyponatremia

the latter becoming a completely different case

Thank you so much to my neurologist and pharmacist colleagues at the University of Illinois health system, and the Johns hopkins University

for examining the more intricate details of KC's case and thank you so much for watching

Take care of yourself and be well