Severe Hyperkalemia (K⁺ 7.2 mEq/L) Requires Immediate ICU-Level Care
A potassium of 7.2 mEq/L is a life-threatening emergency that mandates immediate admission to an intensive care unit or emergency department with continuous cardiac monitoring and emergent treatment, regardless of symptoms or ECG findings. This level carries extreme risk of fatal ventricular arrhythmias, cardiac arrest, and sudden death 1, 2.
Why ICU/Emergency Department Care Is Mandatory
Severe hyperkalemia is defined as K⁺ >6.0 mEq/L, and your patient's level of 7.2 mEq/L far exceeds this threshold, placing them at imminent risk of life-threatening cardiac complications 1, 2.
The European Society of Cardiology explicitly recommends hospital admission for any patient with severe hyperkalemia (>6.0 mEq/L), ECG changes, or symptoms due to the high risk of cardiac arrhythmias and sudden death 1.
Treatment must begin immediately—do not delay while arranging transport or awaiting repeat laboratory confirmation if clinical suspicion is high, as even minutes matter in preventing fatal arrhythmias 1.
Immediate Emergency Management Protocol
First Priority: Cardiac Membrane Stabilization (Within 1-3 Minutes)
Administer calcium gluconate 10% (15-30 mL IV over 2-5 minutes) or calcium chloride 10% (5-10 mL IV over 2-5 minutes) to stabilize the cardiac membrane and prevent arrhythmias 1, 2.
This does not lower potassium but protects the heart from the electrical effects of hyperkalemia, with onset of action in 1-3 minutes 1.
If no ECG improvement occurs within 5-10 minutes, repeat the calcium dose 1.
Obtain a 12-lead ECG immediately to assess for peaked T waves, flattened P waves, prolonged PR interval, widened QRS complex, or sine-wave pattern—any of these findings demands emergency treatment irrespective of the measured potassium level 1.
Second Priority: Shift Potassium Intracellularly (Within 30-60 Minutes)
Give insulin 10 units IV push with 50 mL of 50% dextrose (25 grams) to lower serum potassium by approximately 0.5-1.2 mEq/L within 30-60 minutes 1, 2.
Administer albuterol 10-20 mg nebulized over 10-15 minutes to reduce potassium by an additional 0.5-1.0 mEq/L and augment the insulin effect 1, 2.
Consider sodium bicarbonate 50 mEq IV over 5 minutes only if severe metabolic acidosis is present—it is not effective as monotherapy for hyperkalemia 1.
Third Priority: Remove Potassium from the Body
Initiate sodium zirconium cyclosilicate (SZC/Lokelma) 10g three times daily for 48 hours if available, as it reduces potassium within 1 hour 1.
Give IV furosemide 40-80 mg if the patient has adequate renal function to promote urinary potassium excretion 1.
Arrange urgent hemodialysis consultation immediately—this is the most reliable method for refractory hyperkalemia, severe renal impairment, or ongoing potassium release 1, 2.
Critical Monitoring Requirements
Continuous cardiac telemetry is mandatory for severe hyperkalemia to promptly detect arrhythmias 1.
Recheck serum potassium 1-2 hours after insulin/glucose or albuterol administration, then every 2-4 hours during the acute treatment phase until stable 1.
Monitor for rebound hyperkalemia 2-4 hours after temporary measures wear off, as insulin and albuterol effects are transient 1.
Medication Review and Discontinuation
Immediately discontinue or hold all medications contributing to hyperkalemia: RAAS inhibitors (ACE inhibitors, ARBs), mineralocorticoid receptor antagonists (spironolactone), NSAIDs, and potassium-sparing diuretics 1.
Stop any potassium supplements or salt substitutes containing potassium 1.
Common Pitfalls to Avoid
Never delay treatment while waiting for repeat laboratory values—a potassium of 7.2 mEq/L requires immediate action based on the first measurement 1.
Do not send this patient home or to a lower level of care—outpatient management is absolutely contraindicated at this potassium level 1, 2.
Do not overlook pseudohyperkalemia (hemolysis during blood draw), but treat first and confirm later if clinical suspicion is high 1.
Failing to arrange hemodialysis consultation early is a critical error—at K⁺ 7.2 mEq/L, medical management alone may be insufficient 1, 2.