Episode 86 – Emergency Management of Hyperkalemia

This is 'A Nuanced Approach to Emergency Management of Hyperkalemia' on EM Cases. Of all the electrolyte emergencies, hyperkalemia is the one that has the greatest potential to lead to cardiac arrest. And so, early in my EM training I learned to get the patient on a monitor, ensure IV access, order up an ECG, bombard the patient with a cocktail of kayexalate, calcium, insulin, B-agonists, bicarb, fluids and furosemide, and get the patient admitted, maybe with some dialysis to boot. Little did I know that some of these therapies were based on theory alone while others were based on a few small poorly done studies. It turns out that some of these therapies may cause more harm than good, and that precisely when and how to give these therapies to optimize patient outcomes is still not really known. There are many questions in my mind that remain unanswered when it comes to the ED management of hyperkalemia: What exactly are the indications for giving Calcium? Is calcium strictly contra-indicated in patients on digoxin, or are them some situations in which we should give dig patients calcium? Which is better to stabilize the cell membrane and prevent dysrhythmias from hyperkalemia, Calcium gluconate or calcium chloride? When we give insulin, aren’t we causing an unacceptably high number of patients to become hypoglycemic? Is there any role for kayexalate in the ED? Which fluids are the best to help eliminate K through the kidneys? Should we try eliminating K through the GI tract with laxatives? Should bicarb ever be used in treating hyperkalemia? How soon after we give these treatments should we expect an improvement in the potassium level? Is there a danger in giving B-agonists first, before other treatments? In the hyperkalemic cardiac arrest patient, should we push for dialysis intra-arrest? With the help of Dr. Melanie Baimel and Dr. Ed Etchells, who you may remember from Episode 60 Emergency Management of Hyponatremia, we will answers these questions and many more... Written Summary and blog post written by Michael Kilian, edited by Anton Helman September, 2016 Cite this podcast as: Helman, A, Baimel, M, Etchells, E. Emergency Management of Hyperkalemia. Emergency Medicine Cases. September, 2016. https://emergencymedicinecases.com/alcohol-withdrawal-delirium-tremens/. Accessed [date]. General Approach to Emergency Management of Hyperkalemia Place the patient on a cardiac monitor, establish IV access and obtain an ECG ↓ If the patient is stable, consider the cause and rule out pseudohyperkalemia (from poor phlebotomy technique, thrombocytosis or leucocytosis) and repeat the potassium to confirm hyperkalemia. ↓ Stabilize the cardiac membrane with Calcium Gluconate 1-3 amps (or Calcium Chloride 1 amp if peri-arrest/arrest) if: a) K>6.5 or b) wide QRS or c) absent p waves or d) peri-arrest/arrest ↓ Drive K into cells with 2 amps D50W + Regular Insulin 10 units IV push followed by B-agonists 20mg by neb or 8 puffs via spacer if: a) K>5 with any hyperkalemia ECG changes or b) K>6.5 regardless of ECG findings ↓ Eliminate K through the kidneys and GI tract while achieving euvolemia and establish good urine flow Normal Saline IV boluses if hypovolemia Furosemide IV only if hypervolemic PEG 3350 17g orally for alert patients remaining in your ED for prolonged period of time Dialysis for arrest, peri-arrest, dialysis patient or severe renal failure ↓ Monitor rhythm strip, glucose at 30 mins,