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Water intoxication
From Wikipedia, the free encyclopedia
Water intoxication (also known as hyperhydration or water poisoning) is a potentially fatal disturbance in brain function that results when the normal balance of electrolytes in the body is pushed outside of safe limits by a very rapid intake of water.[1]
Physiology of water intoxication
Body fluids contain electrolytes (particularly sodium compounds, such as sodium chloride) in concentrations that must be held within very narrow limits. Water enters the body orally or intravenously and leaves the body primarily in the urine, sweat and by exhaled water vapour. If water enters the body more quickly than it can be removed, body fluids are diluted and a potentially dangerous shift in electrolyte balance occurs.
Most water intoxication is caused by hyponatremia, an overdilution of sodium in the blood plasma, which in turn causes an osmotic shift of water from extracellular fluid (outside of cells) to intracellular fluid (within cells). The cells swell as a result of changes in osmotic pressure and may cease to function. When this occurs in the cells of the central nervous system and brain, water intoxication is the result. Additionally, many other cells in the body may undergo cytolysis, wherein cell membranes that are unable to stand abnormal osmotic pressures rupture, killing the cells. Initial symptoms typically include light-headedness, sometimes accompanied by nausea, vomiting, headache and/or malaise. Plasma sodium levels below 100 mmol/L (2.3g/L) frequently result in cerebral edema, seizures, coma, and death within a few hours of drinking the excess water. As with alcohol poisoning, the progression from mild to severe symptoms may occur rapidly as the water continues to enter the body from the intestines or intravenously.
A person with two healthy kidneys can excrete about 900ml (0.24 gal)/hr[2]. Consuming as little as 1.8 litres of water (0.48 gal) in a single sitting may prove fatal for a person adhering to a low-sodium diet, or 3 litres (0.79 gallons) for a person on a normal diet. However, this must be modulated by potential water losses via other routes. For example, a person who is perspiring heavily may lose 1 L/hr (0.26 gal) of water through perspiration alone, thereby raising the threshold for water intoxication. The problem is further complicated by the amount of electrolytes lost in urine or sweat, which is variable within a range controlled by the body's regulatory mechanisms. Water intoxication can be prevented by consuming water that is isotonic with water losses, but the exact concentration of electrolytes required is difficult to determine and fluctuates over time, and the greater the time period involved, the smaller the disparity that may suffice to produce electrolyte imbalance and water intoxication.
Sodium is not the only mineral that can become overdiluted from excessive water intake. Magnesium is also excreted in urine. According to the National Institutes of Health, "magnesium deficiency can cause metabolic changes that may contribute to heart attacks and strokes."[3] Intravenous magnesium is used in cardiac care units for cardiac arrhythmias.[4]
[edit] Persons at high risk of water intoxication
[edit] Infants
It can be very easy for children under a year old to absorb too much water – especially if the child is under nine months old. [5]
[edit] Runners
Marathon runners are susceptible to water intoxication if they drink only water while running. Although sweat is relatively hypotonic compared with body fluids, marathon runners perspire heavily for long periods, potentially causing their sodium levels to drop when they consume large amounts of fluids to quench their thirst. The replacement fluids may not contain sufficient sodium to replace what has been lost, and this puts them at high risk for water intoxication. Medical personnel at marathon events are trained to immediately suspect water intoxication when runners collapse or show signs of confusion. Properly designed electrolyte-replacement drinks and some sports drinks include electrolytes that make them roughly isotonic with sweat, which helps to prevent water intoxication.
Note that overconsumption of sodium (in drinks or also in food), as well as inadequate intake of water, can cause hypernatremia, a disorder that is nearly the opposite of water intoxication and equally dangerous. Improper use of salt tablets can cause hypernatremia also.
[edit] Overexertion and heat stress
Any activity or situation that promotes heavy sweating can lead to water intoxication when water is consumed to replace lost fluids. Persons working in extreme heat and/or humidity for long periods must take care to drink and eat in ways that help to maintain electrolyte balance. Persons using drugs such as MDMA may overexert themselves, perspire heavily, and then drink large amounts of water to rehydrate, leading to electrolyte imbalance and water intoxication. Even persons who are resting quietly in extreme heat or humidity may run the risk of water intoxication if they drink large amounts of water over short periods for rehydration.
[edit] Psychiatric conditions
Psychogenic polydipsia is the psychiatric condition in which patients feel compelled to drink large quantities of water, thus putting them at risk for water intoxication. This condition can be especially dangerous if the patient also exhibits other psychiatric indications (as is often the case), as his or her care-takers might misinterpret the hyponatraemic symptoms.
[edit] Unusual water losses in disease
Diarrhea and vomiting can result in very large electrolyte losses, and although drinking water will replace lost water, the lost electrolytes may not be adequately replaced, which can result in water intoxication. Replacement fluids for vomiting and diarrhea should be properly balanced to make them isotonic with the fluids lost in these conditions. Special formulations exist for oral rehydration therapy in these cases.
A great many disorders can affect electrolyte balance, especially disorders of the kidneys. Diuretic therapy, mineralocorticoid deficiency, osmotic diuresis (as in the hyperglycemia of uncontrolled diabetes), and the multiple disorders associated with AIDS are other common causes of electrolyte imbalance, although they do not always produce water intoxication.
[edit] Iatrogenic water intoxication
When an unconscious person is being fed intravenously (for example, total parenteral nutrition (TPN)) or via a nasogastric tube), the fluids given must be carefully balanced in composition to match fluids and electrolytes lost. If the fluids administered are hypotonic with respect to fluids lost, electrolyte imbalance and water intoxication may result. The latter may not be immediately obvious in an unconscious patient. The electrolyte status of patients on TPN must be monitored carefully even when they are ambulatory.
[edit] Drug users
Sometimes users of marijuana or other substances will consume large quantities of water in order to receive a negative urinalysis test for that substance.
Water Intoxication has also been linked to over-consumption of water due to the effects of MDMA. Although many cases of this clearly involved individuals drinking large amounts of water, there are cases where there is no evidence of excessive water consumption. Their cases may be caused by MDMA inducing release of the antiduretic hormone vasopressin by the pituitary gland. This causes one to retain water to a greater extent. The death of British teen Leah Betts may be the most widely publicised MDMA-related fatality, and resulted from her consuming too much water due to concerns over dehydration. Signs of hyponatremia include confusion, nausea, headache and loss of consciousness. Hyponatremia in MDMA users is a medical emergency and requires prompt treatment. In general, females are at greater risk of developing symptoms and dying from hyponatremia than males.
[edit] Treatment
Mild intoxication may remain asymptomatic and require only fluid restriction. In more severe cases, treatment consists of:
Diuretics to increase urination, which are most effective for excess blood volume
Saline given intravenously to restore sodium electrolyte levels
Vasopressin receptor antagonists
[edit] Prevention of water intoxication
Water intoxication can be prevented if a person's intake of water and electrolytes closely matches his or her losses. The body's regulatory mechanisms provide a very generous margin of safety if the two are imbalanced, but some extreme activities (such as heavy, prolonged physical exertion), as well as disease states, can overwhelm or impair these mechanisms. Avoid situations that provoke extreme or prolonged perspiration. Drinking fluids that are specially balanced to replace lost electrolytes can also help to prevent intoxication. Eating regularly can provide needed electrolytes if only normal water is available for rehydration.
Sports drinks are popular among athletes because they provide the necessary electrolytes to support extended exercise. They help keep the body balanced and carrying the right amount of fluids. However, not all drinks advertised as sports drinks are suitable for this purpose, and professional advice should be sought for potentially risky situations such as those described above.
Note that a person's innate sense of thirst is more sensitive to overall dehydration than to changes in electrolytes. Thus, it is possible to develop water intoxication while trying to satisfy thirst, if one drinks a great deal of water over a short period. A dangerous drop in electrolytes, such as the hyponatremia that leads to water intoxication, will not have any effect on thirst if one is sufficiently dehydrated.
For people suffering from dehydration due to the heavy perspiration associated with heavy exertion or heat stress, drinking water to rehydrate is much more important than avoiding water intoxication, since the former is extremely common and the latter is rare. One should never avoid drinking water under such conditions; instead, other steps should be taken to ensure that electrolytes are replaced as well, as noted above.
[edit] Notorious cases of water intoxication
In a much-publicized case of fraternity hazing, four members of the Chi Tau (Formally Delta Sigma Phi) House at California State University, Chico pled guilty to forcing 21-year-old student Matthew Carrington to drink excessive amounts of water while performing calisthenics in a frigid basement as part of initiation rites on February 2, 2005.[6] He collapsed and died of heart failure due to water intoxication.
New Zealand race-walker Craig Barrett collapsed during the last kilometer of the 50 km walk in the 1998 Commonwealth Games in a non-fatal case of water intoxication.
On January 12, 2007, Jennifer Strange, a 28-year-old woman from Rancho Cordova, California, was found dead in her home by her mother hours after trying to win a game console in KDND 107.9 "The End" radio station's "Hold Your Wee for a Wii" contest, which involved drinking large quantities of water without urinating. Every 15 minutes contestants were given a bottle of water to drink. It was reported that original amounts were very small (250 mL, 8 fl. oz.) and the bottle size increased as contestants progressed. On January 15 the radio station suspended the show, and the following day John Geary, vice president and general manager of KDND's parent company, Entercom/Sacramento, fired the three hosts of KDND-FM's "Morning Rave" (Trish, Maney, and Lukas) and seven other employees, two of which were the On-Air personalities "Carter" and "Fester". The "Morning Rave" had been on the air for about five years and was one of the capital's top-ranked morning drive programs. In all, according to witness reports, Strange may have drunk nearly two gallons. Afterward, she appeared ill when she went on the air, one contestant said. Following the contest, Strange called in sick to work. About five hours later she was found dead at her home. In the studio, Ybarra said Strange showed fellow contestants photographs of her two sons and daughter, for whom she was hoping to win the Wii. The game console retails for about $250 but, at the time of the competition, it was sold-out throughout North America and was almost impossible to find yet very sought-after.[7][8] Gina Sherrod, who competed with Strange in the contest, said her family listened to the radio show, and told her that a nurse was on air warning that drinking too much water is dangerous. Sherrod said a DJ rebuffed the nurse, saying the contestants signed waivers, however it was later reported these waivers addressed only publicity issues and did not mention health or safety concerns. Sherrod said she had no idea what risk she had taken until she saw news of Strange's death.[9][10][11][12][13]
Other notable fatalities due to water intoxication include Leah Betts,[14] Anna Wood, [15] 2002 Boston Marathon competitor Cynthia Lucero,[16] and Washington, D.C. police officer James McBride.[17]
Water intoxication
From Wikipedia, the free encyclopedia
Water intoxication (also known as hyperhydration or water poisoning) is a potentially fatal disturbance in brain function that results when the normal balance of electrolytes in the body is pushed outside of safe limits by a very rapid intake of water.[1]
Physiology of water intoxication
Body fluids contain electrolytes (particularly sodium compounds, such as sodium chloride) in concentrations that must be held within very narrow limits. Water enters the body orally or intravenously and leaves the body primarily in the urine, sweat and by exhaled water vapour. If water enters the body more quickly than it can be removed, body fluids are diluted and a potentially dangerous shift in electrolyte balance occurs.
Most water intoxication is caused by hyponatremia, an overdilution of sodium in the blood plasma, which in turn causes an osmotic shift of water from extracellular fluid (outside of cells) to intracellular fluid (within cells). The cells swell as a result of changes in osmotic pressure and may cease to function. When this occurs in the cells of the central nervous system and brain, water intoxication is the result. Additionally, many other cells in the body may undergo cytolysis, wherein cell membranes that are unable to stand abnormal osmotic pressures rupture, killing the cells. Initial symptoms typically include light-headedness, sometimes accompanied by nausea, vomiting, headache and/or malaise. Plasma sodium levels below 100 mmol/L (2.3g/L) frequently result in cerebral edema, seizures, coma, and death within a few hours of drinking the excess water. As with alcohol poisoning, the progression from mild to severe symptoms may occur rapidly as the water continues to enter the body from the intestines or intravenously.
A person with two healthy kidneys can excrete about 900ml (0.24 gal)/hr[2]. Consuming as little as 1.8 litres of water (0.48 gal) in a single sitting may prove fatal for a person adhering to a low-sodium diet, or 3 litres (0.79 gallons) for a person on a normal diet. However, this must be modulated by potential water losses via other routes. For example, a person who is perspiring heavily may lose 1 L/hr (0.26 gal) of water through perspiration alone, thereby raising the threshold for water intoxication. The problem is further complicated by the amount of electrolytes lost in urine or sweat, which is variable within a range controlled by the body's regulatory mechanisms. Water intoxication can be prevented by consuming water that is isotonic with water losses, but the exact concentration of electrolytes required is difficult to determine and fluctuates over time, and the greater the time period involved, the smaller the disparity that may suffice to produce electrolyte imbalance and water intoxication.
Sodium is not the only mineral that can become overdiluted from excessive water intake. Magnesium is also excreted in urine. According to the National Institutes of Health, "magnesium deficiency can cause metabolic changes that may contribute to heart attacks and strokes."[3] Intravenous magnesium is used in cardiac care units for cardiac arrhythmias.[4]
[edit] Persons at high risk of water intoxication
[edit] Infants
It can be very easy for children under a year old to absorb too much water – especially if the child is under nine months old. [5]
[edit] Runners
Marathon runners are susceptible to water intoxication if they drink only water while running. Although sweat is relatively hypotonic compared with body fluids, marathon runners perspire heavily for long periods, potentially causing their sodium levels to drop when they consume large amounts of fluids to quench their thirst. The replacement fluids may not contain sufficient sodium to replace what has been lost, and this puts them at high risk for water intoxication. Medical personnel at marathon events are trained to immediately suspect water intoxication when runners collapse or show signs of confusion. Properly designed electrolyte-replacement drinks and some sports drinks include electrolytes that make them roughly isotonic with sweat, which helps to prevent water intoxication.
Note that overconsumption of sodium (in drinks or also in food), as well as inadequate intake of water, can cause hypernatremia, a disorder that is nearly the opposite of water intoxication and equally dangerous. Improper use of salt tablets can cause hypernatremia also.
[edit] Overexertion and heat stress
Any activity or situation that promotes heavy sweating can lead to water intoxication when water is consumed to replace lost fluids. Persons working in extreme heat and/or humidity for long periods must take care to drink and eat in ways that help to maintain electrolyte balance. Persons using drugs such as MDMA may overexert themselves, perspire heavily, and then drink large amounts of water to rehydrate, leading to electrolyte imbalance and water intoxication. Even persons who are resting quietly in extreme heat or humidity may run the risk of water intoxication if they drink large amounts of water over short periods for rehydration.
[edit] Psychiatric conditions
Psychogenic polydipsia is the psychiatric condition in which patients feel compelled to drink large quantities of water, thus putting them at risk for water intoxication. This condition can be especially dangerous if the patient also exhibits other psychiatric indications (as is often the case), as his or her care-takers might misinterpret the hyponatraemic symptoms.
[edit] Unusual water losses in disease
Diarrhea and vomiting can result in very large electrolyte losses, and although drinking water will replace lost water, the lost electrolytes may not be adequately replaced, which can result in water intoxication. Replacement fluids for vomiting and diarrhea should be properly balanced to make them isotonic with the fluids lost in these conditions. Special formulations exist for oral rehydration therapy in these cases.
A great many disorders can affect electrolyte balance, especially disorders of the kidneys. Diuretic therapy, mineralocorticoid deficiency, osmotic diuresis (as in the hyperglycemia of uncontrolled diabetes), and the multiple disorders associated with AIDS are other common causes of electrolyte imbalance, although they do not always produce water intoxication.
[edit] Iatrogenic water intoxication
When an unconscious person is being fed intravenously (for example, total parenteral nutrition (TPN)) or via a nasogastric tube), the fluids given must be carefully balanced in composition to match fluids and electrolytes lost. If the fluids administered are hypotonic with respect to fluids lost, electrolyte imbalance and water intoxication may result. The latter may not be immediately obvious in an unconscious patient. The electrolyte status of patients on TPN must be monitored carefully even when they are ambulatory.
[edit] Drug users
Sometimes users of marijuana or other substances will consume large quantities of water in order to receive a negative urinalysis test for that substance.
Water Intoxication has also been linked to over-consumption of water due to the effects of MDMA. Although many cases of this clearly involved individuals drinking large amounts of water, there are cases where there is no evidence of excessive water consumption. Their cases may be caused by MDMA inducing release of the antiduretic hormone vasopressin by the pituitary gland. This causes one to retain water to a greater extent. The death of British teen Leah Betts may be the most widely publicised MDMA-related fatality, and resulted from her consuming too much water due to concerns over dehydration. Signs of hyponatremia include confusion, nausea, headache and loss of consciousness. Hyponatremia in MDMA users is a medical emergency and requires prompt treatment. In general, females are at greater risk of developing symptoms and dying from hyponatremia than males.
[edit] Treatment
Mild intoxication may remain asymptomatic and require only fluid restriction. In more severe cases, treatment consists of:
Diuretics to increase urination, which are most effective for excess blood volume
Saline given intravenously to restore sodium electrolyte levels
Vasopressin receptor antagonists
[edit] Prevention of water intoxication
Water intoxication can be prevented if a person's intake of water and electrolytes closely matches his or her losses. The body's regulatory mechanisms provide a very generous margin of safety if the two are imbalanced, but some extreme activities (such as heavy, prolonged physical exertion), as well as disease states, can overwhelm or impair these mechanisms. Avoid situations that provoke extreme or prolonged perspiration. Drinking fluids that are specially balanced to replace lost electrolytes can also help to prevent intoxication. Eating regularly can provide needed electrolytes if only normal water is available for rehydration.
Sports drinks are popular among athletes because they provide the necessary electrolytes to support extended exercise. They help keep the body balanced and carrying the right amount of fluids. However, not all drinks advertised as sports drinks are suitable for this purpose, and professional advice should be sought for potentially risky situations such as those described above.
Note that a person's innate sense of thirst is more sensitive to overall dehydration than to changes in electrolytes. Thus, it is possible to develop water intoxication while trying to satisfy thirst, if one drinks a great deal of water over a short period. A dangerous drop in electrolytes, such as the hyponatremia that leads to water intoxication, will not have any effect on thirst if one is sufficiently dehydrated.
For people suffering from dehydration due to the heavy perspiration associated with heavy exertion or heat stress, drinking water to rehydrate is much more important than avoiding water intoxication, since the former is extremely common and the latter is rare. One should never avoid drinking water under such conditions; instead, other steps should be taken to ensure that electrolytes are replaced as well, as noted above.
[edit] Notorious cases of water intoxication
In a much-publicized case of fraternity hazing, four members of the Chi Tau (Formally Delta Sigma Phi) House at California State University, Chico pled guilty to forcing 21-year-old student Matthew Carrington to drink excessive amounts of water while performing calisthenics in a frigid basement as part of initiation rites on February 2, 2005.[6] He collapsed and died of heart failure due to water intoxication.
New Zealand race-walker Craig Barrett collapsed during the last kilometer of the 50 km walk in the 1998 Commonwealth Games in a non-fatal case of water intoxication.
On January 12, 2007, Jennifer Strange, a 28-year-old woman from Rancho Cordova, California, was found dead in her home by her mother hours after trying to win a game console in KDND 107.9 "The End" radio station's "Hold Your Wee for a Wii" contest, which involved drinking large quantities of water without urinating. Every 15 minutes contestants were given a bottle of water to drink. It was reported that original amounts were very small (250 mL, 8 fl. oz.) and the bottle size increased as contestants progressed. On January 15 the radio station suspended the show, and the following day John Geary, vice president and general manager of KDND's parent company, Entercom/Sacramento, fired the three hosts of KDND-FM's "Morning Rave" (Trish, Maney, and Lukas) and seven other employees, two of which were the On-Air personalities "Carter" and "Fester". The "Morning Rave" had been on the air for about five years and was one of the capital's top-ranked morning drive programs. In all, according to witness reports, Strange may have drunk nearly two gallons. Afterward, she appeared ill when she went on the air, one contestant said. Following the contest, Strange called in sick to work. About five hours later she was found dead at her home. In the studio, Ybarra said Strange showed fellow contestants photographs of her two sons and daughter, for whom she was hoping to win the Wii. The game console retails for about $250 but, at the time of the competition, it was sold-out throughout North America and was almost impossible to find yet very sought-after.[7][8] Gina Sherrod, who competed with Strange in the contest, said her family listened to the radio show, and told her that a nurse was on air warning that drinking too much water is dangerous. Sherrod said a DJ rebuffed the nurse, saying the contestants signed waivers, however it was later reported these waivers addressed only publicity issues and did not mention health or safety concerns. Sherrod said she had no idea what risk she had taken until she saw news of Strange's death.[9][10][11][12][13]
Other notable fatalities due to water intoxication include Leah Betts,[14] Anna Wood, [15] 2002 Boston Marathon competitor Cynthia Lucero,[16] and Washington, D.C. police officer James McBride.[17]
