A Mom drank three gallons of water in two hours. This is what happened to her brain. 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 KC 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 KC 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 KC 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 KC 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 that the vision 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. KC 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 KC 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 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 us 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 KC 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 apartment 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% 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% 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.