hyponatremia and anemia?

[81FSUseminole]

hopefully your expertise can shed some light on a pt's condition i had the other day.

i had the same pt on two separate occasions approx 3 days apart.

day 1: mechanical fall, hematoma to occiput, sleepy but otherwise neuro intact (attributed sleepiness to high dose narcotics at home. also, baseline per daughter), very wide pulse pressure (physician attributed this to anti htn meds). something didn't sit right w/ me regarding her presentation. despite my suggestion to the MD that maybe we should investigate further, he decided to D/C home. no baseline labs were ever sent. her CT of head and EKG were benign.

day 2: i notice the lady's name in triage and c/c of anemia. she is brought back to me. very pale, wide pulse pressures and bradycardic w/ strong peripheral pulses. apparently when she followed up a couple days after her initial visit her PMD drew labs. her H/H were 7.8 and 27ish, respectively and her Na+ was 117. her neuro was the same from her previous visit, sleepy but GCS 15. we subsequently obtained a second CT of head and were going to transfuse 2 unit PRBC.

my shift ended before i received CT report or further labs (urine osmolality, etc). im just slightly bothered by the fact that all too often work ups are done on those that don't need them and neglected on those that do.

was her anemic and hyponatremic state likely caused by the head injury and SIADH? also, would the PRBC replacement adequately correct her sodium by fluid shift? lastly, in her situation, what could i attribute the wide pulse pressures to other than BP med? for example, BP 120/38 on both arms.

for some reason osmosis has always confused me.

none of her previous labs from prior admission indicated anemia.

thanks!

[UM Review RN, ASN, RN]

From my experience with the geriatric population, it'd be the other way around -- the patient's fall was caused by the anemia. If her GCS was OK and her troponins were OK, then the next logical place to look for the bleed would be the abdomen. Hyponatremia could've been caused by a number of things, but that definitely could've been a contributor to the fall.

I don't have a clue about the pulse pressure question, though. I've noticed that it's fairly common in elderly, so it could be from medications.

Did she have SIADH for her history? Maybe that has something to do with the Na loss?

[81FSUseminole]

the fall was mechanical, not syncopal. i know that Siadh can be triggered w/ a head injury. wish i stayed around to see the second CT report.

[Virgo_RN, BSN, RN]

There's not really enough info to say. What did her lungs sound like? Any JVD? Edema? What did her renals look like? What medications does she take?

[morte, LPN, LVN]

http://www.wrongdiagnosis.com/h/hypertension/book-diseases-13a.htm

[Medic2RN, BSN, RN, EMT-P]

Thank you, very interesting website!