Episode 86 – Emergency Management of Hyperkalemia from Dr. Anton Helman and colleagues is another outstanding tutorial that every primary care clinician might want to review. Link above is to the show notes and podcast.
What follows is only some excerpts from the show notes above:
General Approach to Emergency Management of Hyperkalemia
Place the patient on a cardiac monitor, establish IV access and obtain an ECG
If the patient is stable, consider the cause and rule out pseudohyperkalemia (from poor phlebotomy technique, thrombocytosis or leucocytosis) and repeat the potassium to confirm hyperkalemia.
Stabilize the cardiac membrane with Calcium Gluconate 1-3 amps
(or Calcium Chloride 1 amp if peri-arrest/arrest) if:
a) K>6.5 or
b) wide QRS or
c) absent p waves or
Drive K into cells with 2 amps D50W + Regular Insulin 10 units IV push
followed by B-agonists 20mg by neb or 8 puffs via spacer if:
a) K>5 with any hyperkalemia ECG changes or
b) K>6.5 regardless of ECG findings
Eliminate K through the kidneys and GI tract while achieving euvolemia and establish good urine flow
Normal Saline IV boluses ifhypovolemia
Furosemide IV only ifhypervolemic
PEG 3350 17g orally for alert patients remaining in your ED for prolonged period of time
Dialysis for arrest, peri-arrest, dialysis patient or severe renal failure
Monitor rythym strip, glucose at 30 mins, K and ECG at 60 mins
and repeat as needed until the K is below 6, ECG has normalized and/or dialysis has been started
Be sure to see the rest of the outstanding post which covers:
- The ECG in Emergency Management of Hyperkalemia
- The classic ECG progression in hyperkalemia
- Peaked T wave (K approx 5.5-6.5)
- Prolonged PR interval and flattening or disappearance of the P wave (K approx 6.5-7.5)
- Widening of the QRS
- Sine Wave: pre-terminal rhythm
- Determine the Cause of Hyperkalemia
- First rule out pseudohyperkalemia which accounts for 20% of hyperkalemia lab values.Pseudohyperkalemia is caused by hemolyzed sample, poor phlebotomy technique leukocytosis or thrombocytosis.Then treat the underlying cause:
- Medications: ACEi, Potassium sparing diuretics, B-Blockers, NSAIDs, Trimethoprim (Septra) and Non-prescription salt substitutes
- Renal Failure
- Cell death: Secondary to rhabdomyolisis, massive transfusion, crush or burn injuries.
- Acidosis: Consider Addisons crisis, primary adrenal insufficiency and DKA
- PEARL: If hyperkalemia cannot be explained by any other cause and the patient has unexplained hypotension, draw a random cortisol and ACTH level and give 100 mg IV solucortef for presumed adrenal insufficiency
Be sure to review the entire show notes as there is much more in them than these excerpts (which are here only for my study notes)
Visit Emerg ency Medicine Cases Summaries for a complete list of all the topics they have covered so far (and all are just as helpful as this episode).
Here is a link to the Episode 86 PDF show notes summary.