Note to myself: As always, Dr. Helman’s EMC post and podcast is outstanding. So in treating a patient with an elevated serum potassium review the entire show notes of Episode 86 – Emergency Management of Hyperkalemia.
And review the podcast from time to time as it is an incredibly complete review of hyperkalemia.
In this post I link to and excerpt from Emergency Medicine Cases’ Episode 86 – Emergency Management of Hyperkalemia [Link is to the podcast and show notes].
Written Summary and blog post written by Michael Kilian, edited by Anton Helman September, 2016
When hyperkalemia is suspected the drill is:
- immediately connect patient to a monitor
- Get a secure or two IVs.
- Get 12 lead ECG
- Get labs
- Treat if serum potassium is 5.0 – 6.4 or ≥ 6.5 even if there are no ECG changes
Here are excerpts [again with the caveat that when treating a patient with hyperkalemia review the entire show notes for hyperkalemia to be sure you consider all aspects of the diagnosis and treatment]:
[Possible Symptoms of Hyperkalemia]It can cause:*
- Muscle fatigue.
- Abnormal heart rhythms (arrhythmias)
- Nausea.[Another list of hyperkalemia symptoms]*
- tiredness or weakness.
- a feeling of numbness or tingling.
- nausea or vomiting.
- trouble breathing.
- chest pain.
- palpitations or irregular heartbeats.
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.
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 if hypovolemia
Furosemide IV only if hypervolemic
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
Update 2017: A recent retrospective study suggested that in patients with renal insufficiency and hyperkalemia, administration of 5 units of insulin rather than 10 units significantly decreased the incidence of hypoglycemia while correcting potassium to a similar degree. For ED patients with hyperkalemia and renal insufficiency, consider either lowering the initial dose of insulin from 10 units to 5 units, or ensuring that 2 amps of D50W (rather than 1) is administered concurrently to avoid hypoglycemia. Abstract
Again, the above is just the bare bones of this wonderful resource, so review the entire show notes when confronting a patient with potential hyperkalemia.