In a patient with significant hyponatremia, what is the most appropriate initial treatment?

In cases of significant hyponatremia, particularly when the patient presents with symptoms such as confusion, seizures, or altered mental status, the most appropriate initial treatment is to administer hypertonic saline, specifically 3% NaCl. This solution is effective because it increases the serum sodium concentration more rapidly than isotonic solutions, which is critical in acute settings to prevent potential neurological complications.

Hypertonic saline (like 3% NaCl) can be given as a continuous infusion, commonly starting at a rate of around 30 mL/hr, allowing careful monitoring of the serum sodium levels to prevent overly rapid correction, which can lead to osmotic demyelination syndrome. This approach is designed to increase sodium levels in a controlled manner and improve the patient's clinical status.

Other options, such as administering isotonic saline or a bolus of 0.9% sodium chloride, are less appropriate in acute severe hyponatremia because they do not sufficiently increase serum sodium levels to correct the condition effectively. Discontinuing all current medications may not directly address the immediate need to raise serum sodium and could lead to complications if the medications are necessary for other underlying conditions the patient may have. Therefore, the targeted use of hypertonic saline is