Hypertonic Salt Bomb

A 23.4% hypertonic saline (HTS) infusion (referred to as a “salt bomb”) is primarily indicated for cases of refractory intracranial hypertension as seen in traumatic brain injury, large strokes, and malignant cerebral edema. HTS generates an osmotic shift to draw water out of swollen brain tissue to reduce intracranial pressure (ICP). In cases of imminent brain herniation, a salt bomb can temporize the ICP until a more definitive intervention (e.g., decompressive hemicraniectomy) is performed.

Salt bombs can also be used in cases of severe, symptomatic hyponatremia (remember not to overcorrect!) Due to its extremely hypertonic nature (~8,008 mOsm/L!), salt bombs are preferably administered through a central line (watch for extravasation/thrombophlebitis when given peripherally) and infused over several minutes. Potential complications include hypernatremia, hyperchloremic acidosis, renal impairment, and rebound intracranial hypertension. Additionally, given its high osmolarity, there’s a risk of volume overload, which can exacerbate pulmonary edema or heart failure in susceptible patients.