Appendix B: Hypertonic Saline Protocol

Hypertonic (3% saline) may be delivered via peripheral IV or intraosseous access.

1. Give 250cc 3% sodium chloride (NaCl) bolus IV (children 5 cc/kg) over 10–15 minutes.

2. Follow bolus with infusion of 3% NaCl at 50 cc/hour.

3. If awaiting transport; check serum Na+ levels every hour:

- If Na < 150 mEq/L re-bolus 150 cc over 1 hour then resume previous rate
- If Na 150–154, increase NaCl infusion 10 cc/hour.
- If Na 155–160, continue infusion at current rate.
- If Na >160, hold infusion, recheck in 1 hour.

4. Once Na is within the range- continue to follow the serum Na+ level every 6 hours

5. After cessation of 3% NaCl infusion, and there is no further concern for cerebral edema the Na Levels should be lowered gradually back to the normal range. Recommend decreasing Na by 5mEq/L each day until normal and continuing to monitor at regular intervals for 24hrs after cessation of hypertonic saline.

6. A 30cc Bolus of 23.4% NaCl can also be given over 10-15 minutes. Can be given as IV piggyback or as an IV push over 10-15 minutes by an experienced provider.