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 stepwise approach: first stabilize cardiac membranes with IV calcium, then shift potassium into cells with insulin/glucose and beta-agonists, and finally eliminate potassium from the body through diuretics, potassium binders, or hemodialysis. 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 indicating urgent treatment include peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes 3, 2
• ECG findings can be variable and less sensitive than laboratory tests in predicting hyperkalemia or its complications 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 (500-1000 mg) 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, 1
• 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 can be used as an adjunct to insulin/glucose 3, 2
• For patients with concurrent metabolic acidosis, sodium bicarbonate (50 mEq IV over 5 minutes) may be beneficial 3, 1

Step 3: Eliminate Potassium from Body

• Administer loop diuretics such as furosemide 40-80 mg IV in patients with adequate renal function 3, 2
• Consider potassium binders:
  • Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally 3
  • Note: FDA labeling states that sodium polystyrene sulfonate should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 4
  • Newer potassium binders (patiromer, sodium zirconium cyclosilicate) are safer alternatives for chronic management 1, 2
• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 3

Important Clinical Considerations

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours), and rebound hyperkalemia can occur 2
• Monitor potassium levels closely during treatment to avoid overcorrection and hypokalemia 2
• Review and adjust medications that may contribute to hyperkalemia, such as ACE inhibitors, ARBs, NSAIDs, and beta-blockers 1, 2
• A team approach involving specialists, primary care physicians, and other healthcare professionals is optimal for chronic hyperkalemia management 1, 5

Common Pitfalls and Caveats

• Absent or atypical ECG changes do not exclude the necessity for immediate intervention in severe hyperkalemia 6
• Sodium bicarbonate is effective primarily in patients with concurrent metabolic acidosis and should not be used as monotherapy for hyperkalemia 1, 6
• Potassium binders like sodium polystyrene sulfonate have a delayed onset of action and should not be relied upon for emergency treatment 4
• Calcium administration does not lower serum potassium but only protects against cardiac arrhythmias 3, 2
• The combination of sorbitol with sodium polystyrene sulfonate may increase the risk of intestinal necrosis and is not recommended 1