What is the treatment for hyperkalemic emergencies, including doses and frequencies of each medication?

Treatment of Hyperkalemic Emergencies

For hyperkalemic emergencies (K+ ≥6.5 mEq/L or any ECG changes), immediately administer IV calcium gluconate 15-30 mL (10%) over 2-5 minutes to stabilize cardiac membranes, followed by insulin 10 units with 50 mL of 50% dextrose (D50W) IV and nebulized albuterol 20 mg over 15 minutes to shift potassium intracellularly. 1, 2, 3

Initial Assessment

Before initiating aggressive treatment, verify this is true hyperkalemia and not pseudohyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique by repeating the measurement with proper technique or arterial sampling. 1, 3

Obtain an ECG immediately to look for peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes—these findings mandate urgent treatment regardless of the potassium level, though ECG changes are highly variable and less sensitive than laboratory values. 1, 2

Step 1: Cardiac Membrane Stabilization (Immediate - Within 1-3 Minutes)

Administer IV calcium immediately if K+ >6.5 mEq/L or any ECG changes are present. 2, 3

Dosing Options:

• Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes (preferred for peripheral IV access) 1, 2, 3
• Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes (preferred for central access; provides more rapid increase in ionized calcium but requires central line due to tissue necrosis risk with extravasation) 2

Key Points:

• Effects begin within 1-3 minutes but last only 30-60 minutes 1, 2
• Calcium does NOT lower serum potassium—it only protects against arrhythmias 1, 2
• Monitor heart rate during administration and stop if symptomatic bradycardia occurs 2
• Can repeat dose if ECG changes persist after 5-10 minutes 2

Step 2: Shift Potassium into Cells (Onset 15-30 Minutes, Duration 4-6 Hours)

Administer all three agents simultaneously for maximum effect:

Insulin with Glucose (Most Reliable Agent)

• Insulin: 10 units regular insulin IV 1, 2, 3
• Glucose: 50 mL of 50% dextrose (D50W) or 25g glucose IV over 15-30 minutes 1, 2
• Onset: 15-30 minutes; Duration: 4-6 hours 1, 2
• Critical: Always give glucose with insulin to prevent hypoglycemia 1, 3
• Monitor glucose closely, especially in patients with low baseline glucose, no diabetes, female sex, or altered renal function 1
• Can repeat every 4-6 hours if hyperkalemia persists, monitoring potassium every 2-4 hours 1

Nebulized Beta-2 Agonist

• Albuterol (salbutamol): 10-20 mg nebulized over 15 minutes 1, 2, 3
• Alternative: Fenoterol 10-20 mg nebulized over 15 minutes 2
• Onset: 15-30 minutes; Duration: 2-4 hours 1, 2
• Can be used alone or to augment insulin effect 4
• Reduces serum potassium by approximately 0.5-1.0 mEq/L 2

Sodium Bicarbonate (ONLY if Metabolic Acidosis Present)

• 50 mEq (50 mL of 8.4% solution) IV over 5 minutes 1, 2
• Use ONLY if pH <7.35 and bicarbonate <22 mEq/L 1, 3
• Onset: 30-60 minutes 1
• Do NOT use in patients without metabolic acidosis—it is ineffective and potentially harmful 1, 3

Step 3: Eliminate Potassium from Body (Definitive Treatment)

Loop Diuretics (If Adequate Renal Function)

• Furosemide: 40-80 mg IV 1, 2, 3
• Effective only in patients with adequate kidney function 1, 2
• Increases renal potassium excretion by stimulating flow to collecting ducts 1

Hemodialysis (Most Effective Method)

• Indicated for: Severe hyperkalemia unresponsive to medical management, oliguria, end-stage renal disease, or K+ >6.5 mEq/L refractory to other measures 1, 2
• Most reliable and effective method for potassium removal 1, 2, 4
• Rapidly and reliably removes potassium 4

Potassium Binders (Subacute Treatment)

Newer Agents (Preferred):

• Sodium zirconium cyclosilicate (SZC/Lokelma): 10 g orally three times daily for 48 hours, then 5-15 g once daily for maintenance 1

  • Onset: 1 hour 1
  • Effective for both acute (K+ ≥5.8 mEq/L) and chronic management 1

• Patiromer (Veltassa): 8.4 g orally once daily, titrated up to 25.2 g daily based on potassium levels 1

  • Onset: ~7 hours 1
  • Better for chronic management 1

Older Agent (Use with Caution):

• Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally 2, 5
  • NOT for emergency use due to delayed onset of action 5
  • Average adult dose: 15-60 g daily orally (divided 1-4 times daily) or 30-50 g rectally every 6 hours 5
  • Contraindicated with sorbitol due to risk of intestinal necrosis 1, 5
  • Significant limitations including delayed onset and risk of bowel necrosis 1
  • Administer at least 3 hours before or after other oral medications 5

Critical Monitoring and Follow-Up

• Monitor potassium every 2-4 hours initially after treatment to detect rebound hyperkalemia 1
• Rebound hyperkalemia can occur after 2 hours because insulin/glucose and albuterol provide only transient effects (1-4 hours) 2
• Monitor for hypoglycemia after insulin administration 1, 3
• Monitor calcium and magnesium levels, as potassium binders are not totally selective 5

Common Pitfalls to Avoid

• Do NOT rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 1, 3
• Do NOT use sodium bicarbonate without metabolic acidosis—it is only indicated when acidosis is present 1, 3
• Always give glucose with insulin to prevent hypoglycemia 1, 3
• Remember that calcium, insulin, and beta-agonists do NOT remove potassium from the body—they only temporize, requiring definitive removal strategies 1, 3
• Avoid sodium polystyrene sulfonate with sorbitol due to intestinal necrosis risk 1, 5

Medication Review

Identify and eliminate contributing medications: ACE inhibitors, ARBs, mineralocorticoid antagonists, NSAIDs, beta-blockers, potassium supplements, salt substitutes, trimethoprim, and heparin. 1, 2, 3

For patients on RAAS inhibitors with cardiovascular disease, consider maintaining these life-saving medications using newer potassium binders (patiromer or SZC) rather than discontinuing therapy. 1, 2