Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- Place on monitor; obtain STAT ECG and BMP.
- If ECG changes or K+ ≥6.0 → give IV calcium immediately; repeat as needed.
- Give insulin + dextrose; consider nebulized albuterol; give sodium bicarbonate if severe acidosis.
- Start removal strategy: loop diuretic if diuresis possible; otherwise arrange urgent hemodialysis.
- Identify/stop offending meds; correct hypocalcemia/hypomagnesemia; address underlying AKI.
- Serial K+ checks every 1–2 h until stable; admit to monitored setting.
Clinical Synopsis & Reasoning
ECG changes or K+ ≥6.0 mEq/L require immediate IV calcium for membrane stabilization, insulin/dextrose and beta‑agonist for intracellular shift, and measures to remove potassium (loop diuretics, binders, or dialysis). Identify and treat precipitating causes.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| 12‑lead ECG + telemetry | Arrhythmia risk | Peaked T waves, wide QRS | Repeat after therapy |
| BMP, Mg, venous blood gas | Severity/acid‑base | Hyperkalemia ± acidosis | Guide bicarbonate use |
| Medication review | Identify causes | ACEi/ARB, K‑sparing diuretics, AKI | Stop contributors |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Calcium gluconate 10% 1 g IV (repeat PRN) | Membrane stabilization | Minutes | For ECG changes/severe hyperkalemia | Use calcium chloride via central line |
| Regular insulin 10 units IV + 25 g dextrose | Shift K+ intracellularly | Minutes | Re‑check K+ in 60 min | Use dextrose first if euglycemic |
| Nebulized albuterol 10–20 mg | β2‑agonist | Minutes | Adjunct K+ shift | Tachycardia; less effective on β‑blockers |
| Loop diuretic and isotonic fluids | Renal excretion | Hours | If volume overloaded but with urine output | Monitor volume status |
| Hemodialysis | Removal | Immediate | Definitive in anuric/AKI or refractory cases | Coordinate access/anticoagulation |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- UK Kidney Association Clinical Practice Guideline: Management of Hyperkalaemia in Adults (2023 update of 2020) — Link