What is the most critical therapy to administer to a pulseless patient with a wide complex rhythm after initial epinephrine (adrenaline) administration?

Calcium Gluconate for Hyperkalemia-Induced Cardiac Arrest

In this patient with end-stage kidney disease who missed two dialysis sessions and presents with pulseless wide complex rhythm refractory to initial epinephrine, calcium gluconate is the most critical therapy to administer immediately, as this clinical picture strongly suggests life-threatening hyperkalemia requiring urgent membrane stabilization. 1

Clinical Context and Diagnosis

This patient's presentation is classic for hyperkalemia-induced cardiac arrest:

• End-stage kidney disease with missed dialysis sessions creates the highest risk scenario for severe hyperkalemia 1
• Wide complex rhythm in a pulseless patient with this history is hyperkalemia until proven otherwise 1
• Refractory to initial epinephrine suggests a metabolic cause (hyperkalemia) rather than primary cardiac etiology 1

Why Calcium Gluconate is Critical Now

Calcium provides immediate cardiac membrane stabilization in hyperkalemia-induced arrhythmias, working within minutes to counteract the effects of elevated potassium on cardiac conduction 1. This is distinct from other treatments:

• Epinephrine has already been given (1 mg) without response, and the next dose isn't due for 3-5 minutes 1
• Amiodarone is only indicated for shock-refractory VF/pVT after defibrillation and epinephrine have been initiated, and is specifically for primary ventricular arrhythmias, not metabolically-induced wide complex rhythms 1
• Sodium bicarbonate may help shift potassium intracellularly but works more slowly than calcium and is a secondary intervention 1

Treatment Algorithm for This Patient

Immediate Actions (Next 30 Seconds)

1. Administer calcium gluconate 10% solution, 10-20 mL IV push over 2-3 minutes while continuing chest compressions 1
2. Continue high-quality CPR without interruption during calcium administration 1
3. Prepare sodium bicarbonate (50 mEq IV) as the next intervention 1

Subsequent Management (Next 2-5 Minutes)

1. Give epinephrine 1 mg IV at the 3-5 minute mark per standard ACLS protocol 1, 2
2. Administer sodium bicarbonate 50 mEq IV push to help shift potassium intracellularly 1
3. Consider insulin/glucose (10 units regular insulin with 25g dextrose) to drive potassium into cells 1

Definitive Treatment

1. Prepare for emergency hemodialysis if ROSC is achieved, as this is the only definitive treatment for severe hyperkalemia in ESRD 1

Why Other Options Are Incorrect

Amiodarone

• Indicated only for shock-refractory VF/pVT after defibrillation attempts 1
• This patient has a wide complex rhythm (likely PEA or organized rhythm from hyperkalemia), not VF/pVT requiring defibrillation 1
• Does not address the underlying metabolic cause of the arrest 1

Epinephrine (Repeat Dose)

• While epinephrine should be continued every 3-5 minutes, it's not yet time for the next dose (only 2 minutes have elapsed) 1
• Epinephrine alone will not reverse hyperkalemia-induced conduction abnormalities without membrane stabilization 1, 2
• For non-shockable rhythms, epinephrine improves ROSC but must be combined with treatment of reversible causes 1, 2

Sodium Bicarbonate

• Works more slowly than calcium for cardiac protection in hyperkalemia 1
• Should be given after calcium as a secondary intervention 1
• Helps shift potassium intracellularly but doesn't provide immediate membrane stabilization 1

Critical Pitfalls to Avoid

Do not delay calcium administration while waiting for laboratory confirmation of hyperkalemia—the clinical scenario (ESRD, missed dialysis, wide complex arrest) is sufficient to warrant empiric treatment 1. The risk of calcium in a non-hyperkalemic patient is minimal compared to the mortality of untreated hyperkalemic arrest.

Do not confuse calcium chloride with calcium gluconate dosing—calcium chloride contains three times more elemental calcium per gram and requires different dosing 1. Calcium gluconate 10-20 mL of 10% solution is the standard dose 1.

Do not stop CPR to administer medications—all drugs should be given during ongoing chest compressions with minimal interruptions 1.

Remember the "H's and T's" of reversible causes during cardiac arrest, with hyperkalemia being one of the most immediately treatable causes in this clinical context 1.