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Hyperkalemia
Key considerations: Cardiac arrest from hyperkalemia, Pseudo-hyperkalemia (hemolyzed sample)
Cannot miss
- Cardiac arrest from hyperkalemia
- Pseudo-hyperkalemia (hemolyzed sample)
Likely diagnoses
- CKD
- ACEi/ARB/MRA use
- Rhabdomyolysis
- Adrenal insufficiency
- Acidosis
Red flags
- K >6.5
- ECG changes (peaked T, wide QRS, sine wave)
- Weakness
- Cardiac arrest
Workup
- history: Medications (ACEi, ARB, K-sparing diuretics, TMP-SMX), diet, kidney disease; exam: Weakness, cardiac exam; labs: BMP (repeat if suspected hemolysis), ECG, CBC, glucose; imaging: Not typically needed; bedside: 12-lead ECG immediately
Management
- immediate: ECG changes present: calcium gluconate 1g IV over 2-3min (cardiac membrane stabilization); Insulin 10 units regular + D50 25g IV (shifts K intracellularly); Albuterol 10-20mg nebulizer; general: Kayexalate 30g PO or patiromer for K removal (slow); Loop diuretic if not anuric; Emergent dialysis if refractory or K >7 with ECG changes
Disposition
- admit: K >6.0, ECG changes, recurrent hyperkalemia, AKI; discharge: Mild hyperkalemia corrected with medication adjustment; consults: Nephrology if dialysis needed
Clinical pearls
- Calcium does NOT lower potassium — it stabilizes cardiac membranes while you work on shifting and removing K
- Pseudohyperkalemia: hemolyzed sample, extreme leukocytosis, or thrombocytosis — always repeat if unexpected
Source and review
- AHA Hyperkalemia Management 2020. Last reviewed: 2024-11-01