Unfortunately, the first symptom of hyperkalemia can be death due to arrhythmia. Severe hyperkalemia, especially with associated EKG changes, should be treated as an emergency.
Our Toolkit to Lower the Potassium Level
(While we simultaneously treat the underlying issue, which may be evaluation and treatment of kidney dysfunction, stopping implicated medications, and more.)
I would recommend using lactated ringers as opposed to normal saline. As ringers contains potassium, this should seem counterintuitive. A nice explanation can be found here.
This immediately improves the potassium level, but the effects are temporary.
- Insulin, with D50 to prevent hypoglycemia.
- Albuterol.
- Sodium bicarbonate to correct acidemia, if present.
This works more slowly, but it is more permanent than shifting the potassium into the cells.
- Loop diuretic such as IV furosemide.
Kayexalate (do not give this to a patient with bowel obstruction or ileus as it can cause intestinal necrosis).
If you can’t get the potassium to a safe level, dialysis will fix the problem, but we like to avoid this outcome, if possible.
Do not give Kayexalate to a patient with bowel obstruction or ileus, as it can cause intestinal necrosis.
Image credit: Eric Tanenbaum.
