Hypertonic Saline
Sodium chloride 3% or 23.4%
Brand names:Generic
Concentrated saline solutions (3% or 23.4%) used as osmotic agents to reduce cerebral edema in traumatic brain injury with signs of herniation, treat severe symptomatic hyponatremia, and support volume resuscitation in specific contexts. TCCC 2026 explicitly adds hypertonic saline for traumatic herniation: 250 mL of 3% or 30 mL of 23.4% IV/IO over at least 10 minutes, may repeat once.
Pharmacology and Actions
Creates an osmotic gradient across the blood-brain barrier, drawing water out of brain tissue into the vascular space, reducing intracranial volume and pressure. The reduced cerebral edema decompresses tissue and may reverse herniation if administered before irreversible neurologic injury. Smaller volume effect than mannitol but with sodium load that supports hemodynamics rather than diuresing. Also draws water from peripheral tissues into vasculature, transiently expanding intravascular volume.
Indications
- Acute traumatic brain injury with signs of herniation (asymmetric or fixed/dilated pupils, posturing) per TCCC 2026
- Severe symptomatic hyponatremia (sodium under 120 mEq/L with seizures or coma)
- Refractory increased intracranial pressure unresponsive to head elevation and sedation
- Volume resuscitation in specific hypotensive head-injured patients (not first-line, used in specific protocols)
Absolute Contraindications
- Severe hypernatremia
- Pulmonary edema with volume overload
- Established overcorrection of chronic hyponatremia (osmotic demyelination risk)
- No absolute contraindications in life-threatening herniation per TCCC 2026
Precautions and Side Effects
Rapid sodium rise can cause osmotic demyelination syndrome (central pontine myelinolysis), particularly in patients with chronic hyponatremia corrected too rapidly. Extravasation causes severe tissue necrosis especially with 23.4%. Volume overload with congestive heart failure. Hyperchloremic metabolic acidosis with prolonged use. Phlebitis at peripheral IV site. Coagulopathy with high doses (sodium-mediated platelet dysfunction).
Adult Dosing
Pediatric Dosing
3% NaCl: 3 to 5 mL/kg IV/IO over 10 to 20 minutes for herniation or severe hyponatremia. Pediatric trauma protocols vary; consult pediatric critical care if available.
Pharmacokinetics
Peak Effect: 10 to 30 minutes
Duration: 2 to 6 hours per dose
Storage and Handling
Room temperature 15 to 30 degrees C. 3% NaCl typically supplied as 500 mL or 250 mL bags. 23.4% NaCl as 30 mL vials or syringes. Shelf life typically 18 to 24 months. Crystallization may occur with cold storage; warm to room temperature before use if observed. Bag spike and infusion technique standard for IV administration.
Reconstitution:
3% solution (513 mEq/L sodium) and 23.4% solution (4004 mEq/L sodium) are ready to use. Do not dilute. Central venous access strongly preferred for 23.4% due to extravasation risk; peripheral IV acceptable in emergency for time-limited administration. Compatibility with most IV medications limited; flush line with NS before and after.
TCCC and TECC Role
TCCC 2026 update explicitly adds hypertonic saline for traumatic herniation as a new doctrinal element. The 250 mL of 3% (or 5%) OR 30 mL of 23.4% IV/IO dose over at least 10 minutes is specified for asymmetric or fixed/dilated pupils or posturing in TBI casualties. Followed by saline flush. May repeat once after 20 minutes. NOT used prophylactically to prevent herniation. NOT used as a resuscitative fluid for hemorrhagic shock. The doctrinal addition reflects accumulating evidence and field experience with hypertonic saline as the preferred osmotic agent over mannitol in tactical and prolonged casualty care settings.
Hypertonic saline for traumatic herniation is one of the most significant TCCC 2026 additions. Mannitol historically held this role in civilian trauma but requires refrigeration, has variable bioavailability, and produces diuresis that worsens shock in hypovolemic trauma patients. Hypertonic saline is room-temperature stable, supports hemodynamics rather than depleting volume, and has demonstrated equivalent or superior outcomes in TBI management. The TCCC 2026 doctrine is specific: signs of herniation (unequal or fixed pupils, posturing) trigger administration, not just elevated ICP or moderate TBI. The drug is escalation therapy for the dying brain, not maintenance for the injured brain. Concurrent hypertonic saline use does not replace other TBI management priorities (oxygenation, blood pressure support, head elevation, evacuation to neurosurgical capability).
Using hypertonic saline as a resuscitative fluid for hemorrhagic shock. TCCC 2026 explicitly states hypertonic saline is NOT a resuscitative fluid. The other common mistake is administering hypertonic saline prophylactically to prevent herniation in a TBI casualty without herniation signs; doctrine specifies use only when herniation signs are present (asymmetric or fixed pupils, posturing). A third common mistake is failing to monitor the IV site for extravasation; 3% causes significant local irritation, and 23.4% can cause limb-threatening tissue necrosis.
This drug profile is provided as educational reference material for trained medical providers. It is not medical advice, not a substitute for formal training, and not a substitute for current published guidelines or medical direction.
Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances are subject to additional handling, accountability, and documentation requirements per DEA and state law. Always verify dosing, indications, contraindications, and route of administration against current published guidelines and your local protocols before administration.
If this content is being viewed during a medical emergency, call 911 immediately and follow the direction of your local emergency dispatch and medical control. Do not use this reference as a substitute for emergency medical services.
Drug information evolves. Last reviewed dates and source citations are provided for each entry. Confirm currency against the cited source before clinical use.
Penn Tactical Solutions publishes this reference for educational purposes. PTS does not provide medical direction and does not assume responsibility for clinical decisions made in the field. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Educational reference for trained medical providers. Not medical advice. Not a substitute for formal training, current published guidelines, or medical direction. Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances require additional storage, accountability, and documentation per DEA and state law.
In a medical emergency, call 911. This reference is not a substitute for emergency medical services.
Verify dosing, indications, and contraindications against current published guidelines and your local protocols before administration. Confirm content currency against the source citation. Penn Tactical Solutions does not provide medical direction. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Hypertonic Saline
| IV/IO | TCCC 2026 herniation indication: 250 mL of 3% (or 5%) hypertonic saline IV/IO over at least 10 minutes, OR 30 mL of 23.4% IV/IO over at least 10 minutes. Followed by saline flush. May repeat once after 20 minutes if no response (maximum 2 doses). Severe symptomatic hyponatremia: 100 mL of 3% IV over 10 minutes, may repeat twice; goal is rise of 4 to 6 mEq/L in first 6 hours, avoid greater than 10 mEq/L rise in 24 hours. (Within minutes (osmotic effect rapid)) |
| IM | Not given IM (severe tissue injury) (None) |
| IN | None (None) |
| PO | None (None) |