What is the immediate management of a patient with life‑threatening hyperkalaemia presenting with arrhythmias?

Immediate Management of Life-Threatening Hyperkalemia with Arrhythmias

For a patient presenting with arrhythmias and hyperkalemia, immediately administer IV calcium gluconate 10% (15-30 mL over 2-5 minutes) to stabilize the cardiac membrane, followed simultaneously by insulin 10 units IV with 25g dextrose (50 mL D50W) and nebulized albuterol 10-20 mg to shift potassium intracellularly, then arrange urgent hemodialysis for definitive potassium removal. 1

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

This is your first priority when arrhythmias are present.

• Administer calcium gluconate 10%: 15-30 mL IV over 2-5 minutes as the immediate first-line treatment 1, 2
• Alternatively, use calcium chloride 10%: 5-10 mL (500-1000 mg) IV over 2-5 minutes if central venous access is available, as it provides more rapid ionized calcium concentration 1
• Calcium does NOT lower serum potassium—it only protects against arrhythmias by stabilizing cardiac membranes 1, 3
• The protective effect begins within 1-3 minutes but lasts only 30-60 minutes, so you must simultaneously initiate potassium-lowering therapies 1, 3
• Repeat the calcium dose if ECG does not improve within 5-10 minutes 1, 3
• Monitor continuously during administration and stop if symptomatic bradycardia occurs 1

Critical Pitfall to Avoid:

• Never delay calcium administration while waiting for repeat potassium levels when arrhythmias or ECG changes are present—ECG changes indicate urgent need regardless of the exact potassium value 1, 2

Step 2: Shift Potassium into Cells (Onset 15-30 Minutes)

Administer all three agents together for maximum effect:

Insulin-Glucose (Most Effective)

• Give 10 units regular insulin IV push plus 25g dextrose (50 mL of D50W) over 15-30 minutes 1, 3
• This reduces serum potassium by 0.5-1.2 mEq/L within 30-60 minutes 1, 2
• Effect lasts 4-6 hours 1, 3
• Never give insulin without glucose—hypoglycemia can be fatal 1, 2
• Monitor blood glucose closely, especially in patients with low baseline glucose, no diabetes history, female sex, or impaired renal function 3

Nebulized Beta-2 Agonist (Adjunctive)

• Administer albuterol 10-20 mg in 4 mL nebulized over 10-15 minutes 1, 3, 2
• Lowers potassium by 0.5-1.0 mEq/L within 30 minutes 1, 2
• Duration is 2-4 hours 1, 3
• Can be repeated every 2 hours if needed 1, 2
• The combination of insulin-glucose plus albuterol is more effective than either alone 1, 2

Sodium Bicarbonate (ONLY if Metabolic Acidosis Present)

• Give 50 mEq IV over 5 minutes ONLY when pH < 7.35 and bicarbonate < 22 mEq/L 1, 3, 2
• Onset is slower (30-60 minutes) compared to insulin or beta-agonists 1, 2
• Do NOT use without documented metabolic acidosis—it is ineffective and wastes time 1, 3, 2

Critical Warning:

• These are temporizing measures only—rebound hyperkalemia occurs 2-4 hours after effects wear off 1, 3
• They do NOT remove potassium from the body 1, 2

Step 3: Eliminate Potassium from Body (Definitive Treatment)

Hemodialysis (Most Reliable and Effective)

Hemodialysis is the gold standard for severe hyperkalemia with arrhythmias. 1, 2, 4

Absolute indications for urgent dialysis: 1, 2

• Serum potassium > 6.5 mEq/L unresponsive to medical therapy

• Persistent arrhythmias or ECG changes despite medical management

• Oliguria or anuria

• End-stage renal disease

• Ongoing potassium release (tumor lysis syndrome, rhabdomyolysis)

• Severe renal impairment (eGFR < 15 mL/min)

• In hemodynamically unstable patients, use continuous renal replacement therapy (CRRT) over intermittent hemodialysis to minimize rapid fluid shifts 1, 2

Loop Diuretics (If Adequate Renal Function)

• Administer furosemide 40-80 mg IV to increase renal potassium excretion 1, 3, 2
• Effective only when eGFR > 30 mL/min and patient is non-oliguric 1, 2
• Titrate to maintain euvolemia, not primarily for potassium management 3

Potassium Binders (Sub-acute Management)

• Sodium zirconium cyclosilicate (SZC/Lokelma): 10g three times daily for 48 hours, then 5-15g once daily 1, 3, 2
  • Onset of action: ~1 hour (suitable for urgent scenarios) 1, 3
• Patiromer (Veltassa): 8.4g once daily with food, titrated up to 25.2g daily 1, 3, 2
  • Onset of action: ~7 hours (for sub-acute/chronic control) 1, 3
  • Must be separated from other oral medications by ≥3 hours 3
• Avoid sodium polystyrene sulfonate (Kayexalate) due to risk of bowel necrosis, colonic ischemia, and lack of efficacy data 1, 3, 2

Step 4: Medication Management During Acute Episode

Immediately hold or discontinue: 1, 2

• RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid receptor antagonists) when potassium > 6.5 mEq/L
• NSAIDs
• Potassium-sparing diuretics (spironolactone, amiloride, triamterene)
• Trimethoprim-containing agents
• Heparin
• Beta-blockers
• Potassium supplements and salt substitutes

After acute resolution: 1, 3, 2

• Restart RAAS inhibitors at a lower dose once potassium < 5.0 mEq/L
• Initiate a potassium binder (SZC or patiromer) to enable continuation of life-saving RAAS therapy
• Do NOT permanently discontinue RAAS inhibitors—they provide mortality benefit in cardiovascular and renal disease 1, 3, 2

Monitoring Protocol

Acute Phase:

• Re-measure serum potassium 1-2 hours after insulin/glucose or beta-agonist therapy 1, 2
• Continue potassium checks every 2-4 hours until stable 1, 3, 2
• Obtain repeat ECG to confirm resolution of arrhythmias and cardiac changes 1, 2
• Monitor blood glucose to prevent hypoglycemia from insulin therapy 3

Post-Acute Phase:

• Check potassium within 1 week after initiating or escalating RAAS inhibitors 1, 3
• Reassess 7-10 days after starting a potassium binder 1, 3
• Individualize monitoring frequency based on renal function, heart failure status, diabetes, or prior hyperkalemia episodes 1, 3

Common Pitfalls to Avoid

• Do NOT delay treatment while waiting for repeat lab confirmation if arrhythmias or ECG changes are present 1, 2, 4
• Never give insulin without glucose—hypoglycemia can be fatal 1, 2
• Do NOT use sodium bicarbonate without documented metabolic acidosis (pH < 7.35, bicarbonate < 22 mEq/L) 1, 3, 2
• Remember that calcium, insulin, and beta-agonists are temporizing measures only—they do NOT remove potassium from the body 1, 2
• Do NOT permanently discontinue RAAS inhibitors—use potassium binders to maintain these life-saving medications 1, 3, 2
• Avoid sodium polystyrene sulfonate (Kayexalate) due to serious gastrointestinal complications 1, 3, 2
• Do NOT rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 3

Special Considerations

• Exclude pseudo-hyperkalemia from hemolysis or improper sampling before initiating aggressive treatment 5, 3
• In patients with tumor lysis syndrome or rhabdomyolysis, monitor more frequently (every 2-4 hours) due to ongoing potassium release 1, 2
• DNR orders do NOT preclude urgent dialysis—they only restrict cardiopulmonary resuscitation 1
• Post-dialysis rebound hyperkalemia can occur within 4-6 hours as intracellular potassium redistributes 1, 3