Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- ECG and repeat potassium; give IV calcium for ECG changes or K+ ≥6.5.
- Shift potassium with insulin/dextrose ± β-agonist ± bicarbonate (if acidotic).
- Remove potassium with binders/diuretics/dialysis; identify and treat underlying cause; continuous monitoring.
Clinical Synopsis & Reasoning
Treat hyperkalemia with a three-step sequence: stabilize cardiac membrane (IV calcium), shift K+ intracellularly (insulin/dextrose, β-agonists, bicarbonate if acidotic), and remove K+ (diuretics, potassium binders, or dialysis). Continuous ECG monitoring is essential.
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 |
|---|
| Immediate ECG and repeat potassium level | Risk | Identify life-threatening changes | Confirm true elevation |
| Chemistries/ABG and review of meds | Etiology | Acidosis, renal failure, ACEi/ARBs, K+ supplements | Address causes |
| Urine electrolytes (selected) | Mechanism | Hypoaldosteronism vs renal failure | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| ECG changes (peaked T, widening QRS) | Arrhythmia risk | IV calcium immediately; telemetry |
| K+ ≥6.5 mEq/L or rising rapidly | Life-threatening | Full temporizing cocktail; ICU |
| Renal failure or rhabdomyolysis | Refractory elevation | Dialysis early |
| Digoxin toxicity | Calcium risk debated | Use Digibind; careful with calcium |
| Hemolysis suspected | Pseudohyperkalemia | Repeat plasma level quickly |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Calcium gluconate 1–2 g IV (repeat as needed) | Membrane stabilization | Minutes | Protects myocardium | Use chloride via central line |
| Regular insulin 10 U IV + D25W 25 g (or D50W 50 mL) | Intracellular shift | Minutes | Lowers K+ ~0.6–1.0 mEq/L | Monitor glucose |
| Nebulized albuterol 10–20 mg | β2-agonist | Minutes | Adjunct shift | Tachycardia/tremor |
| Sodium bicarbonate (if acidotic) | Buffer | Minutes | Shift in metabolic acidosis | Limited in euvolemic patients |
| Sodium zirconium cyclosilicate 10 g or Patiromer 8.4–25.2 g | Removal (GI binders) | Hours | Non-emergent removal | Avoid in bowel obstruction |
| Loop diuretics and/or hemodialysis | Removal | Hours | Definitive in renal failure | — |
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
- Nephrology emergency hyperkalemia guidance — Link