Signs and Symptoms
- Generalized weakness
- Palpitations
- Change in urinary pattern
- Tachypnea
History
- Increase oral intake of potassium from food
- Potassium sparing medications
Physical Exam
- Can be normal
- Vital signs: BP: Normal, hyper or hypotension
- General: Generalized weakness
- Cardiovascular: Tachycardia, bradycardia, irregular heart sounds
- Abdomen: Diffuse abdomen tenderness
- Consider spontaneous bacterial peritonitis with patients who are on peritoneal dialysis with abdominal pain. Need to send off peritoneal dialysis fluid, discuss with patient's nephrologist and start on IV antibiotics
- Neuro: Altered mental status, decreased reflexes
- Check for dialysis catheter, fistula, or graft
Essential Workup
- Electrolytes, BUN, creatinine, glucose
- ECG
Diagnostic Tests & Interpretation
Lab
- Electrolytes, BUN, creatinine, glucose
- Elevated BUN/creat: Renal failure
- VBG:
- Acid-base status
- A quick assessment of potassium value
- Urine sodium:
- >25 mEq/L: Calculate transtubular potassium gradient (TTKG) to determine if it is mineralocorticoid deficiency
- <25 mEq/L: Acute kidney injury
- TTKG = [K (urine)/K (blood)] × [Osmolality (blood)/Osmolality (urine)]
- TTKG <6: Impaired aldosterone bioactivity in the distal nephron
- TTKG >6: Potassium overload or cellular shifting
Imaging
- CXR if the patient is short of breath:
- Assess for pulmonary edema, volume overload especially in dialysis patients
- ECG:
- K (>5 mEq/L): Peak T-waves
- K (>6.5-7.5 mEq/L): Loss of P-wave, QRS prolongation, and ectopy
- K (>7.5 mEq/L): Sine wave
Differential Diagnosis
Not limited to the followings:
- Pseudohyperkalemia (hyperkalemia reported by lab as artifact of hemolysis during phlebotomy)
- Diabetes emergencies
- Viral illness
- MI
- CVA
- Dysrhythmias (caused by underlying cardiac disease)
Prehospital
- Monitor
- Vital signs
- Establish IV access if possible
- ECG
- Call for medical direction if the patient is unstable or the ECG is abnormal
- Transport to the nearest ED
Initial Stabilization/Therapy
- Airway, breathing, circulation
- Cardiac monitor
- ECG (repeat even if done by EMS)
- Establish IV access if not done by EMS
- Volume resuscitation if indicated
- Labs (VBG or ABG will give fast assessment of pH and potassium value especially in an emergent situation)
ED Treatment/Procedures
- The main goal is to stabilize the cardiac membrane
- Digoxin toxic patients: If K is >5.5 mEq/L, consider Digibind. Not enough evidence to support whether calcium is harmful in this setting
- Stable patients with mild to moderate hyperkalemia (5.5-7.5 mEq/L) and no ECG changes:
- IV fluid resuscitation if the patient is hypotensive (be cautious not to overload renal failure or CHF patients)
- D50 25 g IV
- Insulin 5-10 mg IV (be cautious with hypoglycemia)
- Calcium gluconate 1 g IV if K is ≥6 mEq/L
- Nebulized albuterol (10-20 mg)
- Treat the underlying cause
- Patients with abnormal vital signs, ECG changes and severe hyperkalemia (>7.5 mEq/L):
- IV fluid resuscitation if the patient is hypotensive (be cautious not to overload renal failure or CHF patients)
- D50 25 g IV
- Insulin 5-10 mg IV (be cautious with hypoglycemia)
- Calcium chloride 1 g IV
- Nebulized albuterol (10-20 mg)
- Consider sodium bicarbonate 50-100 mEq IV if acidotic
- Emergent nephrology consult
- If patient is a dialysis patient: Emergent dialysis
- Cardiac arrest:
- ACLS
- IV fluid resuscitation
- D50 25 g IV
- Insulin 5-10 mg IV
- Calcium chloride 1 g IV
- Sodium bicarbonate 50-100 mEq IV
Medication
- Acute treatment:
- Calcium gluconate 1 g IV
- Calcium chloride 1 g IV
- D50 25 g IV
- Regular insulin 5-10 units IV
- Nebulized albuterol 10-20 mg
- Sodium bicarbonate 50-100 mEq IV
- Subacute treatment:
Disposition
Admission Criteria
- Mild hyperkalemia with ECG changes, abnormal vital signs or persistent hyperkalemia despite treatments
- Moderate hyperkalemia
- Severe hyperkalemia
- New acute renal injury with hyperkalemia
Discharge Criteria
Mild hyperkalemia with no ECG changes, with normal vital signs and resolution of hyperkalemia after treatment
Follow-up Recommendations
Close follow-up with nephrology and primary care physician
- AshurstJ, SergentSR, WagnerBJ, et al. Evidence-based management of potassium disorders in the emergency department [digest] . Emerg Med Pract. 2016;18(11):S1-S2.
- ChoiMJ, ZiyadehFN. The utility of the transtubular potassium gradient in the evaluation of hyperkalemia . J Am Soc Nephrol. 2008;19(3):424-426.
- LevineM, NikkanenH, PallinDJ. The effects of intravenous calcium in patients with digoxin toxicity . J Emerg Med. 2011;40(1):41-46.
- VieraAJ, WoukN. Potassium disorders: Hypokalemia and hyperkalemia . Am Fam Physicians. 2015;92(6):487-495.
See Also (Topic, Algorithm, Electronic Media Element)
The authors gratefully acknowledge Chris Colwell for his contribution to the previous edition of this chapter.