Author: Brad Kinney MD. Emergency Medicine Physician. August 26, 2018.
- Recognize HyperK or the potential for HyperK
- ABCs, monitor, EKG!!! Repeat lab if suspecting iatrogenic hemolysis.
- If EKG changes are present OR potassium>6.0…initiate the treatment below.
- Stabilize the Myocardium
- Calcium Gluconate (10%): 10ml vial IV = 1g of CaGl. Administer via PIV, OR
- Calcium Chloride (10%): 10ml ampule IV = 1g of CaCl. Only administer via CVC due to risk of extravasation injury, or administer emergently via PIV during codes.
- Push K Intracellularly
- Albuterol: 10-20mg nebulized “high-dose” albuterol. Repeat as needed.
- Insulin/Glucose: 5-10 units of insulin per 1 ampule of D50 IV if normoglycemic. If hyperglycemic, hold D50. In ESRD, decrease insulin dose.
- Bicarbonate: 1 ampule = 50mEq NaHCO3. Only consider if acidemic, or administer empirically in crashing patient. Repeat as needed.
- Eliminate K from the body
- IVF: Increases renal excretion of K. Use NS or LR. LR does not worsen hyperK.
- Lasix: 40-80mg IV. If still making urine.
- Dialysis: The ultimate correction for hyperK in renal failure. Temporize with medications until dialysis available.
– Pseudohyperkalemia. Hemolyzed blood sample, most common cause.
– CKD/ESRD. Often missed dialysis.
– Rhabdomyolysis. Myocytes lyse spilling K into the serum.
– Adrenal Insufficiency. Classic triad of hypotension, hyperK, hypoNa.
– Medications. K sparing diuretics, ACEIs, ARBs.
– 5.0-6.0 = “Mild” Hyperkalemia
– 6.1-7.0 = “Moderate” Hyperkalemia
– >7.0 = “Severe” Hyperkalemia
“CLASSIC” EKG CHANGES:
1. T-waves peak
2. PR lengthens, P-waves flatten
3. QRS widens, P-waves disappear
4. Sine-wave appears
5. Ventricular fibrillation, asystole, death
- Physiology. Hyperkalemia causes two separate clinical effects. First, excessive extracellular potassium reduces intracellular potassium efflux making the intracellular environment more positive and the cell membrane potential less electronegative. This increases cardiac myocyte excitability increasing the risk of arrhythmias. Second, worsening hyperkalemia “poisons” sodium channels worsening their function and slowing action potential conduction velocities leading to the widening intervals seen on EKGs.
- There are two different types of calcium that can be given – Calcium Gluconate (CaGl) and Calcium Chloride (CaCl).
- CaGl is stored in 10ml vials in the Pyxis and can be given via PIV. Each vial contains 1 gram of CaGl providing 4.65mEq of elemental calcium.
- CaCl is stored in 10ml prepackaged ampules in the code cart and should not be given via PIV except during codes due to the risk of extravasation injury. Each ampule contains 1 gram of CaCl providing 13.6mEq of elemental calcium.
- One gram of CaCl contains three times the amount of elemental calcium as one gram of CaGl due to the much larger molecular mass of CaGl, so give CaCl in emergent situations due to its higher potency.
Tintinalli, Judith E., et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Eighth edition. Fluids and Electrolytes, Chapter 17, p. 101-106. New York: McGraw-Hill Education, 2016.
- Hilton J et al. Management of Hyperkalemia in the ED. EMResident. 2018; 45(4): issue 4: 22-23. Online article.
- Parham WA et al. Hyperkalemia Revisited. Tex Heart Inst J. 2006; 33(1): 40–47. PMC1413606.
- Farkas J. Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS. Emcrit.org. 2014. Link to Article.
- Ashurst J et al. Evidence-Based Management Of Potassium Disorders In The Emergency Department. Emerg Med Pract. 2016 Nov 22;18. PMID: 27775507.