What is the immediate treatment for a patient presenting with hyperkalemia?

Immediate Treatment for Hyperkalemia

For severe hyperkalemia (≥6.5 mEq/L) or any ECG changes, immediately administer IV calcium gluconate 15-30 mL (10%) over 2-5 minutes to stabilize the cardiac membrane, followed by insulin 10 units IV with 25g glucose (50 mL D50W) and nebulized albuterol 10-20 mg to shift potassium intracellularly. 1, 2

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

Administer calcium first if any of the following are present:

• Potassium ≥6.5 mEq/L 1, 2
• ECG changes: peaked T waves, flattened P waves, prolonged PR interval, widened QRS 1, 2
• Any cardiac arrhythmia 1, 2

Dosing:

• Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes (preferred for peripheral access) 1, 2
• Calcium chloride (10%): 5-10 mL IV over 2-5 minutes (more potent, requires central line when possible) 1, 2

Critical caveats:

• Calcium does NOT lower potassium—it only protects against arrhythmias for 30-60 minutes 1, 2
• If no ECG improvement within 5-10 minutes, repeat the dose 1
• Continuous cardiac monitoring is mandatory during administration 1
• Never administer calcium through the same IV line as sodium bicarbonate (causes precipitation) 1

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

Administer all three agents simultaneously for maximum effect:

Insulin + Glucose:

• 10 units regular insulin IV with 25g glucose (50 mL D50W) over 15-30 minutes 1, 2
• Verify potassium is not below 3.3 mEq/L before giving insulin 1
• Monitor glucose hourly for 4-6 hours to prevent hypoglycemia 1
• Can repeat every 4-6 hours if hyperkalemia persists 1

Beta-2 Agonist:

• Nebulized albuterol 10-20 mg over 15 minutes 1, 2
• Effects last 2-4 hours 1
• Reduces potassium by approximately 0.5-1.0 mEq/L 1

Sodium Bicarbonate (ONLY if metabolic acidosis present):

• 50 mEq IV over 5 minutes 1, 2
• Indicated ONLY when pH <7.35 or bicarbonate <22 mEq/L 1
• Effects take 30-60 minutes to manifest 1
• Do NOT use without documented acidosis—it is ineffective and wastes time 1

Step 3: Eliminate Potassium From Body (Definitive Treatment)

Loop Diuretics (if adequate renal function):

• Furosemide 40-80 mg IV 1, 2
• Effective only if eGFR >30 mL/min 1
• Increases renal potassium excretion 1

Potassium Binders (for subacute/chronic management):

• Sodium zirconium cyclosilicate (SZC/Lokelma): 10g three times daily for 48 hours, then 5-15g once daily 1
  • Onset of action: ~1 hour 1
  • Preferred for more urgent scenarios 1
• Patiromer (Veltassa): 8.4g once daily, titrated up to 25.2g daily 1, 3
  • Onset of action: ~7 hours 1
  • Must be separated from other oral medications by 3 hours 1
  • NOT for emergency treatment due to delayed onset 3

Avoid sodium polystyrene sulfonate (Kayexalate):

• Delayed onset, limited efficacy, and risk of bowel necrosis 1
• Should not be used for acute management 1

Hemodialysis:

• Most effective and reliable method for severe hyperkalemia 1, 2
• Indicated for: potassium >6.5 mEq/L unresponsive to medical therapy, oliguria, end-stage renal disease 1

Step 4: Address Underlying Causes

Immediately review and hold/reduce these medications:

• RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists) if K+ >6.5 mEq/L 4, 1
• NSAIDs 1
• Potassium-sparing diuretics 1
• Trimethoprim, heparin, beta-blockers 1
• Potassium supplements and salt substitutes 1

For K+ 5.0-6.5 mEq/L on RAAS inhibitors:

• Initiate potassium binder and MAINTAIN RAAS inhibitor therapy (these drugs provide mortality benefit) 4, 1
• Do NOT permanently discontinue RAAS inhibitors—use binders to enable continuation 4, 1

Monitoring Protocol

Acute phase (first 6 hours):

• Recheck potassium every 2-4 hours until stabilized 1
• Continuous cardiac monitoring if initial ECG changes present 1
• Monitor glucose hourly after insulin administration 1

After acute resolution:

• Recheck potassium within 1 week of starting potassium binder 1
• Monitor potassium 7-10 days after restarting/adjusting RAAS inhibitors 1
• Individualize frequency based on CKD stage, heart failure, diabetes 1

Critical Pitfalls to Avoid

• Never delay calcium administration while waiting for repeat labs if ECG changes are present 1
• Never use sodium bicarbonate without documented metabolic acidosis 1
• Never give insulin without glucose—hypoglycemia can be life-threatening 1
• Remember that calcium, insulin, and beta-agonists are temporizing only—they do NOT remove potassium from the body 1, 2
• Do NOT rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 1
• Rebound hyperkalemia can occur after 2 hours—initiate definitive potassium removal strategies early 2