2026 Southeastern Residency Conference

Authors: Yasmeen A. Ettrick, Kelly M. Bodine, John Patka, Shauntrell Johnson
Background: Traumatic brain injury (TBI) is a major cause of morbidity and mortality and is frequently complicated by cerebral edema and elevated intracranial pressure. Osmotic therapy with hypertonic saline is a key intervention to mitigate secondary brain injury; clinical guidelines, however, recommend its use for symptomatic neurologic deterioration rather than prophylactic administration. At Grady Memorial Hospital, 3% sodium chloride is commonly used in the emergency department (ED), often prior to neuroimaging due to clinical urgency.
Methods: This single-center, retrospective cohort study was conducted at Grady Memorial Hospital, a Level I trauma center in Atlanta, Georgia. Adult patients (≥18 years) presenting to the emergency department with traumatic brain injury who received at least one dose of 3% sodium chloride between January 1 and June 30, 2024, were included. Patients were excluded for pregnancy, incarceration, non-traumatic indications, transfer from outside facilities, or initial administration after hospital admission. The primary outcome was appropriateness of 3% sodium chloride use, defined by the presence of clinical findings and radiographic evidence of herniation or midline shift. Secondary outcomes included total volume administered and changes in serum sodium and osmolarity.
Results: A total of 65 patients met inclusion criteria, of whom 57 received 3% hypertonic saline prior to CT imaging and 8 received it after imaging. Patients treated prior to CT were younger (median age 40 vs 62 years, p = 0.056) and had lower Glasgow Coma Scale scores (median 4 vs 11, p = 0.013), while hemodynamic parameters were similar between groups. Appropriateness of 3% sodium chloride use was observed in 54.4% of pre-CT administrations compared with 25% post-CT, though this difference was not statistically significant (p = 0.149). Median total volume administered was 500 mL prior to CT and 250 mL after CT, with no significant difference. Median serum sodium increased by 5 mEq/L in the pre-CT group and 4 mEq/L in the post-CT group (p = 0.635), while median serum osmolarity increased by 8 mOsm/L and 3 mOsm/L, respectively (p = 0.45).
Conclusion: In this cohort, 3% hypertonic saline was most often administered before CT imaging, typically in patients with more severe neurologic impairment. Pre-CT administrations were more frequent and more likely to meet guideline criteria than post-CT hypertonic administration, though some still lacked clinical or radiographic indications. Neither pre-CT nor post-CT administration was associated with harmful changes in serum sodium or osmolarity, suggesting that early use may be safe when clinically justified.
Objective: To evaluate the timing, utilization patterns, and physiologic effects of 3% sodium chloride administration in adult ED patients with TBI.
Self-Assessment Question: Identify the recommended indication for hypertonic saline use in adult patients with traumatic brain injury.