What is the treatment for hyperkalemia in a teenager?

Treatment of Hyperkalemia in a 17-Year-Old

For a teenager with hyperkalemia, immediately assess the severity and ECG changes to determine if emergency treatment is needed, then address the underlying cause while implementing acute stabilization measures (calcium for cardiac protection, insulin/glucose and beta-agonists for potassium shifting) followed by definitive potassium removal strategies. 1

Initial Assessment and Classification

First, rule out pseudohyperkalemia from hemolysis, repeated fist clenching during blood draw, or poor phlebotomy technique by repeating the measurement with proper technique or arterial sampling. 1

Classify severity as:

• Mild: 5.0-5.5 mEq/L 2
• Moderate: 5.5-6.0 mEq/L 2
• Severe: ≥6.0 mEq/L 2

Obtain an ECG immediately to look for peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes—these findings indicate urgent treatment regardless of the potassium level. 1 However, do not rely solely on ECG findings as they are highly variable and less sensitive than laboratory tests. 1

Identify the Underlying Cause

In a 17-year-old, investigate these specific causes:

Medication review: Check for NSAIDs, ACE inhibitors, ARBs, potassium-sparing diuretics (spironolactone, amiloride), beta-blockers, trimethoprim-sulfamethoxazole, or heparin. 2

Dietary sources: Assess intake of bananas, oranges, potatoes, tomato products, legumes, yogurt, chocolate, and especially salt substitutes containing potassium. 2

Non-dietary causes: Evaluate for metabolic acidosis, constipation, tissue destruction from infection or trauma, hemolysis (in the body, not just the test tube), and renal function. 2

Acute Management (For Severe or Symptomatic Hyperkalemia)

Step 1: Cardiac Membrane Stabilization (Immediate)

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). 1 This begins working within 1-3 minutes but lasts only 30-60 minutes and does not lower potassium levels—it only protects the heart. 1

Step 2: Shift Potassium Intracellularly (Within 15-30 minutes)

Give insulin 10 units regular insulin IV with 25-50 grams of glucose (to prevent hypoglycemia). 1 This works within 15-30 minutes and lasts 4-6 hours. 1 Monitor glucose closely, especially in patients with low baseline glucose, females, and those with altered renal function who are at higher risk of hypoglycemia. 1

Administer nebulized albuterol 20 mg in 4 mL as adjunctive therapy. 1 Effects last 2-4 hours. 1

If metabolic acidosis is present (pH < 7.35, bicarbonate < 22 mEq/L), add sodium bicarbonate IV. 1 Do not use bicarbonate without concurrent acidosis—it takes 30-60 minutes to work and is only indicated when acidosis is present. 1

Step 3: Remove Potassium from the Body (Definitive Treatment)

For patients with adequate kidney function: Give furosemide 40-80 mg IV to increase renal potassium excretion. 1

For severe hyperkalemia (>6.5 mEq/L) or refractory cases: Hemodialysis is the most reliable and effective method for potassium removal, especially in patients with renal failure or those unresponsive to medical management. 1, 3

For subacute treatment: Sodium polystyrene sulfonate (potassium binder) can be used, but it should not be used as emergency treatment due to delayed onset of action. 4 Newer potassium binders like patiromer or sodium zirconium cyclosilicate are alternatives for chronic management. 1

Chronic Management and Prevention

Dietary modification: Restrict high-potassium foods including bananas, oranges, potatoes, tomato products, legumes, and chocolate. 2 Presoaking root vegetables (including potatoes) lowers potassium content by 50-75%. 2 Absolutely avoid salt substitutes as they typically contain potassium and can cause life-threatening hyperkalemia. 2

Medication adjustment: Review and discontinue or reduce doses of medications contributing to hyperkalemia. 1 Loop or thiazide diuretics can promote urinary potassium excretion. 1

Address constipation and metabolic acidosis as these contribute to hyperkalemia. 2

Monitoring Protocol

Check potassium levels every 2-4 hours after initial acute treatment to assess response and watch for rebound hyperkalemia. 1

For patients on medications affecting potassium homeostasis, reassess potassium 7-10 days after starting or increasing doses. 1

Critical Pitfalls to Avoid

Do not assume normal ECG means safe potassium levels—ECG changes are variable and less sensitive than lab values. 1

Remember that calcium, insulin, and beta-agonists only temporize—they do not remove potassium from the body and effects are temporary. 1

Always give glucose with insulin to prevent potentially dangerous hypoglycemia. 1

Do not use sodium bicarbonate routinely—only when metabolic acidosis is documented. 1

Verify adequate renal function before relying on diuretics for potassium removal. 1