Guideline sources The following summarized guidelines for the evaluation and management of exercise-associated hyponatremia are prepared by our editorial team based on guidelines from the Wilderness Medical Society (WMS 2020). 1 Guidelines 1. Diagnostic investigations Assessment: obtain point-of-care testing in at-risk symptomatic patients when available. Integrate all available clinical and historical information into an assessment of the patient's hydration status (history of fluid intake, food intake, presenting signs and symptoms, body weight if available, and urine output), if testing is unavailable. B 2. Medical management Intravenous fluids: do not administer IV hypotonic fluids in patients with suspected fluid overload exercise-associated hyponatremia. D Show 2 more 3. Inpatient care https://web.pathway.md/diseases/recApOgw6COUOM4Yo 1/2 6/29/23, 4:20 AM Exercise-associated hyponatremia Pathway Transfer of care: inform receiving caregivers about the potential diagnosis of exercise- associated hyponatremia and appropriate fluid management (withhold hypotonic fluids) when transferring care. B Acute inpatient care: avoid administering oral and IV hypotonic or isotonic fluids early in the management of patients with exercise-associated hyponatremia, although, consider using in certain clinical contexts once sodium correction has been initiated or hypovolemia is confirmed. D Show 3 more 4. Nonpharmacologic interventions Oral fluid restriction: advise restricting oral fluids if exercise-associated hyponatremia from fluid overload is associated with mild symptoms. Do not administer hypotonic fluids in patients with suspected exercise-associated hyponatremia. B Oral sodium: consider adding oral sodium in hypertonic solutions or advising foods with high sodium content (salty snacks) for increasing serum sodium levels and enhancing symptom relief (over fluid restriction) in patients with mild exercise-associated hyponatremia, if tolerated. C 5. Preventative measures Proper hydration: advise avoiding sustained overhydration during exercise, as it is the primary risk factor for development of all variants of exercise-associated hyponatremia. A Show 2 more Salt supplementation: advise ensuring freely available sodium and/or salty snacks for consumption along with the appropriate fluid intake, particularly in long, hot events in non-heat acclimatized persons, but recognize that this strategy will not prevent exercise-associated hyponatremia when combined with overdrinking. B 6. Follow-up and surveillance Observation: observe patients for at least 60 minutes after exercise to ensure no decompensation from delayed symptomatic exercise-associated hyponatremia occurs after cessation of exercise. B References 1. Brad L Bennett, Tamara Hew-Butler, Mitchell H Rosner et al. Wilderness Medical Society Clinical Practice Guidelines for the Management of Exercise-Associated Hyponatremia: 2019 Update. Wilderness Environ Med. 2020 Mar;31 1 50 62. Open https://web.pathway.md/diseases/recApOgw6COUOM4Yo 2/2