What is the treatment for cardiac arrest due to hyperkalemia?

Treatment of Cardiac Arrest Due to Hyperkalemia

For cardiac arrest with known or suspected hyperkalemia, intravenous calcium should be administered immediately in addition to standard ACLS care. 1

First-Line Emergency Management

1. Standard ACLS protocol with high-quality CPR

2. Calcium administration (membrane stabilization)

   • Calcium Gluconate 10%: 15-30 mL IV (20 mg/kg or 0.2 mL/kg) over 5-10 minutes 1, 2
   • Onset: 1-3 minutes; Duration: 30-60 minutes
   • Protects the heart from arrhythmias but does not lower potassium levels

3. Potassium shifting agents (administer simultaneously)

   • Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose 2
     • Onset: 15-30 minutes; Duration: 1-2 hours
   • Sodium bicarbonate: 50 mEq IV over 5 minutes 2
     • Onset: 15-30 minutes; Duration: 1-2 hours
     • Recent evidence suggests significant benefit in hyperkalemic cardiac arrest 3
   • Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes 2
     • Onset: 15-30 minutes; Duration: 2-4 hours

Refractory Cases

If no response to the above interventions:

• Consider emergency hemodialysis during ongoing CPR 4, 5, 6, 7
  • Multiple case reports demonstrate successful resuscitation with hemodialysis initiated during CPR when conventional treatments fail
  • In one case, spontaneous heartbeat was restored after 20 minutes of hemodialysis during CPR 5
  • Another case showed recovery after 90 minutes of CPR with simultaneous hemodialysis 6

ECG Monitoring and Recognition

Understanding ECG progression in hyperkalemia is crucial:

• 5.5-6.5 mmol/L: Peaked/tented T waves (earliest sign)
• 6.5-7.5 mmol/L: Prolonged PR interval, flattened P waves
• 7.0-8.0 mmol/L: Widened QRS, deep S waves

• 10 mmol/L: Sinusoidal pattern, VF, asystole, or PEA 2

Important Clinical Considerations

• Do not delay calcium administration while awaiting laboratory confirmation if hyperkalemia is suspected
• Continuous cardiac monitoring is essential during treatment
• Serial potassium measurements should be obtained to guide ongoing therapy
• Avoid IV bolus administration of potassium for cardiac arrest in suspected hypokalemia (Class 3: Harm) 1

Pitfalls to Avoid

1. Delaying calcium administration - This is the most critical immediate intervention for cardiac membrane stabilization
2. Failing to consider hemodialysis early - If conventional therapies are ineffective, hemodialysis during CPR can be lifesaving 4, 5
3. Overlooking the underlying cause - Address the source of hyperkalemia (renal failure, medications, etc.) once the patient is stabilized
4. Inadequate monitoring - Continue monitoring for recurrent hyperkalemia after initial treatment

Recent evidence from a 2024 randomized animal study challenges the efficacy of calcium chloride in hyperkalemic cardiac arrest, showing no significant effect on ROSC, while confirming the benefit of sodium bicarbonate 3. However, current AHA guidelines still strongly recommend calcium administration (Class 1, Level C-LD) 1.