Fatal hypernatremia after using salt as an emetic—report of three autopsy cases

doi:10.1016/j.legalmed.2004.06.005

Legal Medicine

Volume 7, Issue 1, January 2005, Pages 47-50

https://doi.org/10.1016/j.legalmed.2004.06.005 Get rights and content

Abstract

Although a plethora of reports on life-threatening complications of salt emesis has been published since the early 1960s, salt is still used to induce emesis in cases of intoxication in the clinical as well as in the domestic setting. We report three cases of fatal hypernatremia after salt was used as an emetic. All fatalities were subjected to medico-legal autopsy at the Institute of Legal Medicine in Hamburg, Germany. In all cases, symptoms of cerebral damage such as seizures, fever and somnolence developed within hours after salt ingestion. All individuals were admitted to hospital before their deaths. Here, severe hypernatremia (up to 245 mmol/l) was detected, and all patients died under the clinical picture of cerebral edema despite intensive medical treatment. At autopsy, unspecific signs of a central regulatory failure were present. Histology revealed crenated red blood cells and few venous microthrombi in internal organs. Neuropathological investigations yielded no specific results but confirmed fatal cerebral edema and excluded other cerebral causes of death. Viewing the results of clinical and post-mortem investigations together, death could clearly be attributed to excessive salt intake in all cases.

Introduction

The toxicity of great amount of salt has been known for a very long time. It is reported that in ancient China, saturated salt solutions were used as a traditional suicide method. Case reports on fatal salt poisoning and warnings on the use of saline emetics have been published for decades [1], [2], [3], [4], [5]. Likewise, several reports on salt poisoning of other causes, such as gastric lavage [6], intravenous infusion of hypertonic saline [7], forced salt intake in cases of child abuse or exorcism [8], [9] and accidental sodium chloride ingestion due to inadvertent preparation of child food with salt instead of sugar [10]. Despite all these reports, salt is continuously used in first aid for poisoning in households and sometimes even in the clinical setting.

Section snippets

Material and methods

In all cases, medico-legal autopsies were performed within 20 h after death. Routine histology was carried out after fixation in 4% buffered formalin using paraffin embedding and consequent hematoxylin and eosin staining. In addition, the patients' clinical files were analyzed with special regard to blood electrolyte levels.

Case 1

A 34-year-old woman with psychomotor retardation due to bacterial meningitis at the age of 5 months, who lived in a home for disabled people, had ingested two cigarette-ends. The nurse on duty made her to drink two glasses of salt solution, each filled with salt to a height of approximately 6 cm, in order to induce emesis. The woman threw up after half-an-hour. After 1 h, she felt unwell and developed a temperature of 38 °C, but her circulatory parameters were normal. Over the following hours, she

Discussion

Most known cases of hypernatremia are due to a loss of water rather than due to exogenous salt intake. We report three cases of salt poisoning due to excess salt intake in order to induce emesis. The toxicity of salt has been known for a long time. Relatively small amounts of salt can be sufficient to lead to dangerous hypernatremia. The estimated fatal amount is 1 g sodium chloride per kg body weight [5], [11], leading to a rise in blood sodium concentration of about 30 mmol/l [12]. This amount

References (17)

G.A. Gresham et al.
Fatal poisoning with sodium chloride
Forensic Sci Int
(1982)
W.O. Robertson
A further warning on the use of salt as an emetic agent (letter)
J Pediatr
(1971)
V. Hédouin et al.
A case of fatal salt water intoxication following an exorcism session
Forensic Sci Int
(1999)
K.G. Moder et al.
Fatal hypernatremia from exogenous salt intake: report of a case and review of the literature
Mayo Clin Proc
(1990)
J. Barer et al.
Fatal poisoning from salt used as an emetic
Am J Dis Child
(1973)
R.A. Goodboy et al.
Saline emetics and hypernatraemia: report on 2 fatalities
Med Sci Law
(1975)
D.J. Ward
Fatal hypernatraemia after a saline emetic
Br Med J
(1963)
R.F. Carter et al.
Fatal salt poisoning due to gastric lavage with hypertonic saline
Med J Aust
(1971)

There are more references available in the full text version of this article.

Cited by (22)

Salt Toxicity: A Systematic Review and Case Reports
2020, Journal of Emergency Nursing
Salt toxicity is a rare form of hypernatremia that typically occurs after a single massive ingestion of salt over a short period of time (minutes/hours). It is a dangerous imbalance capable of causing significant neurological injury; quick recognition of salt toxicity is crucial to allow treatment before permanent brain injury occurs. The purpose of this review is to assist emergency nurses in gaining knowledge on the causes, pathophysiology, symptoms, and treatment of salt toxicity.
A systematic search for case reports of hypernatremia due to salt toxicity was conducted in the PubMed and Scopus electronic databases. The search terms used were salt, sodium, hypernatremia, toxicity, poisoning, case reports, case series, and cases. The following were the inclusion criteria: publication dates between January 1, 2000, and September 30, 2019; evidence of an acute large oral or gastric tube ingestion of salt over a short period of time (minutes/hours); admission for treatment within hours of the event; laboratory verification of hypernatremia; and full-text article available electronically in English. The following were the exclusion criteria: an unclear history, high salt consumption over a period of days, high sodium intake via the intravenous route, and breast feeding.
Only 15 cases met the inclusion criteria for the review. Patients described in the case reports ranged in age from 5 days to 73 years. Forty percent of the patients were children less than 15 years old. Of the 14 cases with known outcomes, 50% were fatal. The most frequent causes of salt toxicity were salt water emetics, intentional administration of large quantities of salt to a child by a caregiver, and suicide attempts. Among the other causes were unintentional salt overload in infant formula, an exorcism ritual, and a college prank.
Findings from this review of 15 case reports in which a large salt load was ingested over a short period of time suggest that salt toxicity is a rare condition associated with high mortality. In addition, salt toxicity can occur in patients of all ages for a variety of reasons; the most frequently identified reasons in this review were use of salt water as an emetic and child abuse by the intentional administration of a high salt load by a caregiver. For patients whose massive exposure to salt is recent (such as minutes to hours), rapidly reducing the serum sodium concentration may prevent irreversible neurological injury.
Severe hypernatremia due to sea water ingestion in a child
2015, Archives de Pediatrie
Les noyades en eau de mer sont une cause inhabituelle d’hypernatrémie sévère. Nous rapportons le cas d’un enfant de trois ans et demi décédé 11 heures après une noyade en eau de mer avec hypernatrémie grave (178 mmoL/L). Dans ce cas, l’hypernatrémie était aggravée par des diarrhées et par une hyperglycémie avec glycosurie. Classiquement, la correction des hypernatrémies aiguës doit être rapide et précoce avec pour objectif la réduction de la natrémie de 1 à 2 mmoL/L/h.
Drowning in sea water is an unusual cause of severe hypernatremia. We report the case of a 3.5-year-old boy who died 11 h after drowning in sea water, with a serum sodium level of 178 mmoL/L. In this case, hypernatremia was aggravated by diarrhea and hyperglycemia with glycosuria. Usually, correction of acute hypernatremia must be quick and early, aiming at a reduction of serum sodium concentration of up to 1–2 mmoL per liter per hour.
Survival of acute hypernatremia due to massive soy sauce ingestion
2013, Journal of Emergency Medicine
Citation Excerpt :
Adrogué and Madias stated that rapid correction of acute excess sodium ingestion improves prognosis and does not increase the risk of cerebral edema as the brain has not had time to adapt to the increased osmolarity (14). Some authors recommend correction at 1–2 mmol/L/h (1,2). Treatment with these correction rates has produced mixed results.
Intentional massive sodium chloride ingestions are rare occurrences and are often fatal.
There are a variety of treatment recommendations for hypernatremia, ranging from dialysis to varying rates of correction. We report a case of acute severe hypernatremia corrected with rapid free-water infusions that, to our knowledge, has not been previously reported.
A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. He was administered 6 L of free water over 30 min and survived neurologically intact without clinical sequelae. Corrected for hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is the highest documented level in an adult patient to survive an acute sodium ingestion without neurologic deficits.
Emergency physicians should consider rapidly lowering serum sodium with hypotonic intravenous fluids as a potential management strategy for acute severe hypernatremia secondary to massive salt ingestion.
Metabolic Encephalopathies
2011, Neurologic Clinics
The potential significance of elevated vitreous sodium levels at autopsy
2009, Journal of Forensic and Legal Medicine
Elevated levels of sodium that may be detected in the analysis of post-mortem fluid samples may arise from a wide variety of organic illnesses and environmental factors that have caused either water depletion or solute gain. When hypernatraemia is suspected at autopsy a careful history is required with particular emphasis on pre-existing medical conditions such as renal or gastrointestinal disease. In addition, detailed information is required on the circumstances of death, including any clinical symptoms and signs that the deceased may have manifested, or medical procedures such as dialysis, colonoscopy or intravenous fluid replacement. Reduced intake of fluid may be associated with cognitive or physical impairment or may result from environmental depletion (the latter may be a manifestation of inflicted injury). Both central and nephrogenic diabetes insipidus may result in the loss of excessive amounts of hypotonic fluid. This may also occur following diuretic use, or be due to gastroenteritis or burns. Hypernatraemia may be a marker of excessive salt/saline ingestion and/or administration and may occur accidentally or as a manifestation of child abuse. Given the range of possible etiologies, hypernatraemia may be a significant autopsy finding that requires explanation.
Metabolic Encephalopathies
2008, Handbook of Clinical Neurology
Metabolic encephalopathy describes a clinical state of heterogeneous etiology; wherein, cerebral activity is impaired in the absence of parenchymal inflammation or gross structural abnormalities. Metabolic encephalopathy is not a diagnosis but a state of global cerebral dysfunction induced by systemic stress, and can vary in clinical presentation from mild executive dysfunction, to an agitated delirium, to deep coma with decerebrate posturing. This chapter focuses on common causes of metabolic encephalopathy, and outlines the epidemiology, clinical presentation, laboratory and imaging findings, and management. The chapter gives an account for hepatic encephalopathy, uremic encephalopathy, posterior reversible leukoencephalopathy syndrome, pulmonary encephalopathy, pancreatic encephalopathy, and Hashimoto's encephalopathy. Thyroid hormones also act at the level of the mitochondrion to stimulate oxidative metabolism. They also act on the cell membrane to affect the sodium–potassium pump. Adrenal failure is a medical emergency related to a deficiency of adrenal cortical hormones. Electrolyte disturbances are common causes of metabolic encephalopathy. The chapter also describes encephalopathies related to the disruption of sodium, calcium, magnesium, phosphate, and glucose homeostasis.

View all citing articles on Scopus

View full text

Case reportFatal hypernatremia after using salt as an emetic—report of three autopsy cases

Abstract

Introduction

Section snippets

Material and methods

Case 1

Discussion

Forensic Sci Int

J Pediatr

Forensic Sci Int

Mayo Clin Proc

Fatal poisoning from salt used as an emetic

Am J Dis Child

Saline emetics and hypernatraemia: report on 2 fatalities

Med Sci Law

Fatal hypernatraemia after a saline emetic

Br Med J

Fatal salt poisoning due to gastric lavage with hypertonic saline

Med J Aust

Case report
Fatal hypernatremia after using salt as an emetic—report of three autopsy cases