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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 The authors found no children who presented with a subdural and hypernatraemia at presentation. They concluded that if hypernatraemia was present in association with a subdural haemorrhage it was most likely secondary to intracranial pathology, but did not describe a possible mechanism for this. All children under 2 years with a subdural haemorrhage over a six-year period (1 January 1992 to 31 December 1998) in South Wales and Southwest England were reviewed retrospectively. 248, 249 There were 90 cases of subdural haemorrhage confirmed on computed tomography, magnetic resonance imaging, or post mortem examination. Following the finding of cases with associated hypernatraemia, the association was formally reviewed. 250 As hypernatraemia during inpatient admission may occur for multiple medical reasons, only those hypernatraemic at presentation were included, with hypernatraemia defined as serum sodium above 150 mmol/l. The medical records of all potential cases were then reviewed again thoroughly, including all available biochemical and radiological investigations. A total of 4 cases with subdural haemorrhage were identified as being hypernatraemic with the first recorded serum sodium. Two cases were excluded, one because following close review of the medical records the initial sodium at the referring hospital was actually normal. The second child was excluded as they were recovering from meningococcal meningitis, a well-documented infective cause of subdural fluid collections. 251 The 2 cases that did have hypernatraemia at presentation and an associated subdural haemorrhage were both complicated, with other evidence of physical abuse and possible salt poisoning. One of the two cases was fatal. The case series of salt poisoning assembled for this guideline was reviewed to ascertain the frequency of reported subdural haemorrhage. Forty-one children either had a postmortem in which the pathological findings in the brain were reported, a CT scan (10 children), or both (3 children). The causes of their hypernatraemia were as follows: • Salt or saline, 36 • Concentrated feeds, 2 • Sodium bicarbonate, 1 • Water deprivation, 1 • Dehydration, 1 4 65
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 Eight children were thought to have been abused, of whom two children 224, 235 were reported to have a subdural haemorrhage. In one child the subdural was thought to be chronic, in the other its age was not recorded. In one further child 1 of the 33 non-abused children the autopsy report stated “fresh blood was noted in the subdural space diffusely with marked subarachnoid haemorrhage and congestion of the dura and pial vessels. There were no bony abnormalities noted.” This 2-year-old child died after reportedly being given a saline emetic by a babysitter after accidental pill ingestion. A second child, born preterm at 33 weeks, presented aged 5 weeks with a sodium of 214 mEq/L associated with a 24 hours history of lethargy, fever, diarrhoea and vomiting. 252 A right tentorial subdural haematoma, cerebral oedema and intraventricular haemorrhage were found on cranial CT scan. A diagnosis of non-accidental injury was considered, but without other skeletal injuries or retinal haemorrhages the authors attributed the findings to hypernatraemic dehydration. Analysis of the premixed infant formula and the intravenous fluids used demonstrated appropriate sodium concentrations. Fractional urinary sodium excretion was not reported, but there appeared to be a high sodium excretion in the first 15 hours. The infant died 12 hours after admission; no postmortem findings were reported. Both peer reviewers agreed on the balance of probability with the authors’ conclusion that the hypernatraemia was due to dehydration, with the infant being cared for in a hot room (an error by the parent). Among the 25 adults with hypernatraemia with similar information about the presence of a subdural haemorrhage, there was one 35 year old woman 253 with the following description: “thin covering of blood over an area measuring 5 x 4 cm on the surface of the right temporal lobe”. It is unclear whether this relates to a subdural haemorrhage. She had died within a few hours following the administration of a saline emetic as treatment of an overdose. In the event, therefore, there are two cases 1, 252 where subdural haemorrhage and hypernatraemia co-exist and there is no other evidence of child abuse. This is not in itself good evidence that subdural haemorrhage can complicate hypernatraemia, but does not allow a causal connection to be ruled out. 4 The authors' conclusions as to cause were subjected to peer review, see below. 66
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