What are the immediate steps to manage symptoms of hyperkalemia?

Immediate Management of Hyperkalemia

For hyperkalemia with ECG changes or potassium ≥6.5 mEq/L, immediately administer IV calcium gluconate to stabilize cardiac membranes, followed by insulin with glucose and nebulized albuterol to shift potassium intracellularly, then initiate definitive potassium removal strategies. 1

Step 1: Verify the Diagnosis and Assess Severity

• Confirm true hyperkalemia by excluding pseudohyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique before initiating treatment 1
• Obtain an immediate ECG to look for peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes, which indicate urgent treatment regardless of potassium level 1
• Classify severity: mild (5.0-5.9 mEq/L), moderate (6.0-6.4 mEq/L), or severe (≥6.5 mEq/L) 1

Critical pitfall: Do not rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 1

Step 2: Stabilize the Cardiac Membrane (Within 1-3 Minutes)

If potassium >6.5 mEq/L OR any ECG changes are present:

• Administer IV calcium gluconate (10%): 15-30 mL over 2-5 minutes OR calcium chloride (10%): 5-10 mL over 2-5 minutes 1, 2
• Effects begin within 1-3 minutes but last only 30-60 minutes 1
• Repeat the dose if no ECG improvement within 5-10 minutes 1
• Calcium does NOT lower potassium—it only protects the heart temporarily 1, 2

Special consideration: In patients with malignant hyperthermia and hyperkalemia, use calcium only in extremis as it may contribute to calcium overload 1

Step 3: Shift Potassium Intracellularly (Within 15-30 Minutes)

Administer all three agents together for maximum effect:

• Insulin 10 units regular IV + 25g dextrose (50 mL D50W) 1, 2

  • Onset: 15-30 minutes, duration: 4-6 hours 1
  • Verify potassium is not below 3.3 mEq/L before administering insulin 1
  • Monitor glucose closely to prevent hypoglycemia 1
  • Can be repeated every 4-6 hours if hyperkalemia persists 1

• Nebulized albuterol 10-20 mg in 4 mL 1, 2

  • Onset: 15-30 minutes, duration: 2-4 hours 1
  • Augments insulin/glucose effects 3

• Sodium bicarbonate 50 mEq IV over 5 minutes ONLY if metabolic acidosis present (pH <7.35, bicarbonate <22 mEq/L) 1, 2

  • Onset: 30-60 minutes 1
  • Do NOT use without metabolic acidosis—it is ineffective and wastes time 1

Critical pitfall: Never give insulin without glucose—hypoglycemia can be life-threatening 1

Step 4: Remove Potassium from the Body

Choose based on renal function and clinical urgency:

• Loop diuretics (furosemide 40-80 mg IV) if adequate kidney function exists 1, 2

  • Increases renal potassium excretion 1
  • Titrate to maintain euvolemia, not primarily for potassium management 1

• Newer potassium binders (preferred over sodium polystyrene sulfonate):

  • Sodium zirconium cyclosilicate (SZC/Lokelma): 10g three times daily for 48 hours, then 5-15g once daily 1, 4
    • Onset: ~1 hour 1
    • Each 5g dose contains ~400mg sodium—monitor for edema 1, 4
  • Patiromer (Veltassa): 8.4g once daily, titrated up to 25.2g daily 1
    • Onset: ~7 hours 1
    • Separate from other oral medications by at least 3 hours 1

• Hemodialysis is the most effective and reliable method for severe hyperkalemia, especially in patients with renal failure, oliguria, or cases unresponsive to medical management 1, 2, 3

Critical pitfall: Sodium polystyrene sulfonate (Kayexalate) has significant limitations, including delayed onset and risk of bowel necrosis—avoid for acute management 1

Step 5: Address Underlying Causes

Temporarily discontinue or reduce contributing medications when potassium >6.5 mEq/L:

• RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists) 1, 5
• NSAIDs 1
• Potassium-sparing diuretics 1
• Trimethoprim, heparin, beta-blockers 1
• Potassium supplements and salt substitutes 1

Important: Do NOT permanently discontinue RAAS inhibitors—they provide mortality benefit in cardiovascular and renal disease 1. Restart at lower dose once potassium <5.5 mEq/L with concurrent potassium binder therapy 1

Step 6: Monitoring Protocol

• Recheck potassium within 1-2 hours after insulin/glucose or beta-agonist therapy 1
• Continue monitoring every 2-4 hours during acute treatment phase until stabilized 1
• Reassess ECG if initial presentation included cardiac changes to document resolution 1
• Monitor for rebound hyperkalemia, especially in patients with ongoing potassium release (tumor lysis syndrome, rhabdomyolysis) 1

Critical pitfall: Remember that calcium, insulin, and beta-agonists do NOT remove potassium from the body—they only temporize 1. Definitive removal strategies must be initiated simultaneously 2, 3