What is the treatment for hyperkalemia in the Emergency Department (ED)?

Treatment of Hyperkalemia in the Emergency Department

The treatment of hyperkalemia in the ED follows a three-step approach: cardiac membrane stabilization with IV calcium, intracellular potassium shifting with insulin/glucose and beta-agonists, and potassium elimination through diuretics or dialysis. 1, 2

Assessment and Classification

• Hyperkalemia is classified as mild (5.0-5.9 mEq/L), moderate (6.0-6.4 mEq/L), or severe (≥6.5 mEq/L) 1
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 3, 2
• Symptoms may be nonspecific, and ECG findings can be variable and less sensitive than laboratory tests 3

Step 1: Cardiac Membrane Stabilization

• Administer intravenous calcium gluconate (10%): 15-30 mL IV over 2-5 minutes, or calcium chloride (10%): 5-10 mL IV over 2-5 minutes 3, 2
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium 3, 2
• If no effect is observed within 5-10 minutes, another dose of calcium may be given 3

Step 2: Shift Potassium into Cells

• Administer insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 3, 2
• Effects begin within 15-30 minutes and last 4-6 hours 1, 2
• Nebulized albuterol: 10-20 mg over 15 minutes as an adjunctive therapy 3, 2
• Consider sodium bicarbonate (50 mEq IV over 5 minutes) only in patients with concurrent metabolic acidosis 3, 1, 2

Step 3: Eliminate Potassium from Body

• Administer loop diuretics (furosemide 40-80 mg IV) in patients with adequate renal function 3, 2
• Consider potassium binders for non-emergent situations 4
• Note: Sodium polystyrene sulfonate should not be used as an emergency treatment due to its delayed onset of action 4
• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 3, 2

Important Clinical Considerations

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours), and rebound hyperkalemia can occur 1, 2
• Monitor potassium levels closely during treatment to avoid overcorrection and hypokalemia 1, 2
• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, NSAIDs, beta-blockers) 1, 2
• The REVEAL-ED study highlighted a lack of standard, universally accepted treatment protocols for managing hyperkalemia in the emergency department 3

Common Pitfalls and Caveats

• Absence of ECG changes does not exclude the need for immediate intervention in severe hyperkalemia 5, 6
• Sodium bicarbonate is only effective in patients with concurrent metabolic acidosis and should not be used routinely 3, 1, 2
• Potassium binders like sodium polystyrene sulfonate have a delayed onset of action and should not be relied upon for acute management 4
• Calcium administration is contraindicated in patients with malignant hyperthermia except in extreme cases 1
• Rebound hyperkalemia can occur after the effects of temporary measures wear off, necessitating close monitoring 1, 2