What is the emergent treatment for hyperkalemia?

Emergent Treatment of Hyperkalemia

The emergent treatment for hyperkalemia involves immediate administration of calcium gluconate 10% solution (15-30 mL IV) to stabilize cardiac membranes, followed by insulin (10 units regular insulin IV) with glucose (50 mL of 25% dextrose) to shift potassium intracellularly. 1

Initial Assessment and Stratification

• Severity assessment:

  • Mild: 5.0-5.9 mmol/L
  • Moderate: 6.0-6.9 mmol/L
  • Severe: ≥7.0 mmol/L

• ECG changes to monitor:

  • 5.5-6.5 mmol/L: Peaked/tented T waves, nonspecific ST segment abnormalities
  • 6.5-7.5 mmol/L: Prolonged PR interval, flattened or absent P waves
  • 7.0-8.0 mmol/L: Widened QRS, deep S waves, fusion of S and T waves

  • 10 mmol/L: Sinusoidal wave pattern, ventricular fibrillation, asystole, or pulseless electrical activity 1

Step-by-Step Emergent Management Algorithm

1. Cardiac Membrane Stabilization (Immediate)

• Calcium gluconate 10% solution, 15-30 mL IV over 5 minutes
• Onset: 1-3 minutes, Duration: 30-60 minutes 1
• Most effective for main rhythm disorders due to hyperkalemia 2
• May repeat dose if ECG changes persist after 5 minutes

2. Intracellular Potassium Shift (15-30 minutes)

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose

  • Onset: 15-30 minutes, Duration: 1-2 hours 1
  • Consider glucose-only administration in hyperglycemic patients

• Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes

  • Onset: 15-30 minutes, Duration: 2-4 hours 1
  • Can be used in combination with insulin/glucose for additive effect

• Sodium bicarbonate: 50 mEq IV over 5 minutes

  • Onset: 15-30 minutes, Duration: 1-2 hours 1
  • Less effective when used alone
  • Use with caution in fluid-overloaded patients 1

3. Potassium Removal (30-60 minutes)

• Loop diuretics: 40-80 mg IV furosemide

  • Onset: 30-60 minutes, Duration: 2-4 hours 1
  • Ineffective in anuric patients 1

• Hemodialysis:

  • Most reliable method for potassium removal 3
  • Indicated for:
    • Life-threatening hyperkalemia unresponsive to medical therapy
    • Severe hyperkalemia with renal failure
    • Severe hyperkalemia with significant acidosis

• Sodium polystyrene sulfonate (SPS):

  • Not for emergency treatment due to delayed onset of action 4
  • Average adult dose: 15-60g orally (divided into 15g doses 1-4 times daily) 4
  • Rectal administration: 30-50g every 6 hours 4
  • Avoid chronic use, especially with sorbitol, due to risk of bowel necrosis 1

Important Caveats and Pitfalls

• Do not rely on SPS for emergent treatment - FDA specifically states it "should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action" 4

• Avoid potassium-containing fluids (e.g., Lactated Ringer's or Hartmann's solution) in suspected hyperkalemia 1

• Drug interactions: Take other oral medications at least 3 hours before or after SPS 4

• Monitor for rebound hyperkalemia after temporary shifting measures wear off 5

• Absent or atypical ECG changes do not exclude the need for immediate intervention in severe hyperkalemia 6

• Discontinue medications causing hyperkalemia when potassium levels exceed 6.0 mmol/L, particularly RAAS inhibitors 1

Post-Emergency Management

• Recheck potassium and renal function within 2-3 days after intervention 1
• Continue monitoring weekly until stable, then monthly for 3 months 1
• Address underlying causes of hyperkalemia (renal dysfunction, medications, excessive intake)
• Consider newer potassium binders (sodium zirconium cyclosilicate, patiromer) for chronic management 7

Special Considerations

• For patients with heart failure, reintroduce RAAS inhibitors at lower doses as soon as possible after stabilization 1
• Check and correct concurrent hypomagnesemia, which can complicate management 1
• In diabetic patients, monitor glucose levels closely when administering insulin/glucose 5