Hyperkalemia in Emergency Medicine Treatment & Management
- Prehospital Care. In the presence of hypotension or marked QRS widening, intravenous bicarbonate, calcium, and insulin, given together with 50% dextrose, may be appropriate, as discussed in Medication.
- Emergency Department Care. ...
- Consultations. ...
Full Answer
When to treat hyperkalemia?
“Many patients are managed in primary care, with secondary care giving advice and, in some cases, not seeing them for long periods of time. This change will allow people who are living with heart failure and chronic kidney disease, to more readily access treatments that can help manage persistent hyperkalemia.”
What is the emergency treatment of hypokalemia?
- Intravenous KCl should be given at a rate that does not exceed 10 mEq/h. ...
- Administration of IV KCl should be done through a central venous catheter if available. ...
- Potassium chloride salt substitutes are a good source of oral K +. ...
Why am I giving calcium for hyperkalemia?
treatment for severe hyperkalemia (>6.5 mM):
- IV calcium (1 gram of calcium chloride, or 3 grams of calcium gluconate).
- 5 units insulin as an intravenous bolus.
- Dextrose : If glucose <250 mg/dL (<14 mM), give ~two ampules of D50W (100 ml total) –or– ~500 ml of D10W infused over four hours.
- Albuterol : 10-20 mg nebulized (e.g., 4-8 standard nebs back-to-back, or a continuous neb).
When is hyperkalemia an emergency?
Renal failure is the most common cause of hyperkalaemia seen in the emergency department. 1 Clinically significant hyperkalaemia occurs in 5–10% of patients requiring regular haemodialysis. 2 The medical management of hyperkalaemia in chronic renal failure (CRF) is similar to that in acute renal failure (ARF) except that the rate of rise in ARF is usually more rapid and treatment must be more aggressive. 3 Pseudohyperkalaemia (especially from extravascular haemolysis) is probably more ...
General Approach to Emergency Management of Hyperkalemia
Place the patient on a cardiac monitor, establish IV access and obtain an ECG
The ECG in Emergency Management of Hyperkalemia
The ECG changes associated with hyperkalemia do not always happen in a step-wise fashion with predictable serum potassium levels. Although it is generally true that higher levels of potassium correlate with progressive ECG changes, the more acute the hyperkalemia the more likely the ECG changes occur.
Determine the Cause of Hyperkalemia
First rule out pseudohyperkalemia which accounts for 20% of hyperkalemia lab values.
Medications in the Emergency Management of Hyperkalemia
There is no good literature to help guide whether calcium gluconate or calcium chloride is better for stabilizing the cardiac membrane in hyperkalemia. The most important difference to remember is that calcium chloride has 3 times more elemental calcium than calcium gluconate (6.8 mEq/10 mL vs 2.2 mEq/10 mL) and has greater bioavailability.
Hyperkalemia in Cardiac Arrest
Based on the principles of treatment and indications discussed above, our experts recommend the following approach to suspected hyperkalemia (based on patient history and rhythm strip) or confirmed hyperkalemia (based on a point of care blood gas) in cardiac arrest in addition to usual ACLS measures:
Future Directions in Emergency Management of Hyperkalemia
A new potassium binding drug, ZS-9 shows promise in the acute treatment of hyperkalemia and may make it possible to avoid or postpone the most effective therapy, emergency hemodialysis.
About the Author: Anton Helman
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.
What is the blood potassium level of a hyperkalemic patient?
Even if you don't have any symptoms of hyperkalemia, if your blood potassium level is greater than 6.0 mEq/ L , it will be treated as an emergency. 1
What is hyperkalemia in 2021?
Updated on June 28, 2021. Hyperkalemia occurs when you have too much potassium in your blood. Because hyperkalemia is a sign that something else is going on in your body, treatment depends on what's causing it and whether the level of potassium in your blood is judged to be an emergency or not.
How does potassium remover work?
Potassium-removing agents work by binding potassium and exchanging it for other minerals like calcium or sodium. 2 The two that are available to treat hyperkalemia in the United States are Veltassa (patiromer) and Kayexalate (sodium polystyrene sulfonate).
What is the normal level of potassium for a kidney?
If your hyperkalemia is moderate, meaning your serum potassium level is greater than 5.5 mEq but less than 6.5 mEq, and you have normal kidney function or your kidney function is only mildly to moderately impaired, dialysis usually isn't necessary.
What to do if your potassium is 6.0?
Even if you don't have any symptoms of hyperkalemia, if your blood potassium level is greater than 6.0 mEq/ L, it will be treated as an emergency. 1 . In an emergency situation, you will need quick treatment to lower your potassium level. This will include intravenous (IV) calcium and IV insulin with glucose, which usually are given immediately ...
Why do you need to keep dialysis?
You may need to keep having dialysis to prevent hyperkalemia.
What is the procedure called when you have to take potassium out of your body?
2 In this procedure, your blood is filtered through a machine outside of your body, called an artificial kidney or dialyzer , to remove salt, waste, extra water and excess chemicals, including potassium, from your blood.
Why do you need dialysis for hyperkalemia?
So you might need dialysis to treat your kidney disease -- which also treats hyperkalemia.
How to get potassium down when you have hyperkalemia?
Some medications lower potassium slowly, including: Water pills (diuretics), which rid the body of extra fluids and remove potassium through urine. Sodium bicarbonate, which temporarily shifts potassium into body cells.
What medications lower potassium levels?
Some medications lower potassium slowly, including: 1 Water pills (diuretics), which rid the body of extra fluids and remove potassium through urine 2 Sodium bicarbonate, which temporarily shifts potassium into body cells 3 Albuterol, which raises blood insulin levels and shifts potassium into body cells 4 Sodium polystyrene sulfonate (Kayexalate), which removes potassium through your intestines before it’s absorbed 5 Patiromer (Veltassa), which binds to potassium in the intestines 6 Sodium zirconium cyclosilicate (Lokelma), which binds to potassium in the intestines
What causes hyperkalemia in kidneys?
Advanced kidney disease is a common cause of hyperkalemia. A diet high in potassium. Eating too much food that is high in potassium can also cause hyperkalemia, especially in people with advanced kidney disease. Foods such as cantaloupe, honeydew melon, orange juice, and bananas are high in potassium. Drugs that prevent the kidneys ...
How to check potassium level?
A blood test can find the level of potassium in your blood. High potassium is usually found by chance during a routine blood test. Your healthcare provider will also give you a complete physical checkup. You will be asked about your medical history, your diet, and the medicines you take.
Why does potassium increase with diabetes?
This occurs because your body, in response to severe burns or injuries releases extra potassium in your blood. Poorly controlled diabetes. When diabetes is not controlled, it has a direct effect on your kidneys which are responsible for balancing potassium in your body.
Why does potassium rise?
This can cause your potassium levels to rise. Other (less common) causes include: Taking extra potassium , such as salt substitutes or supplements. A disorder called “Addisons disease”, which can occur if your body does not make enough of certain hormones.
How to get potassium out of your body?
Some people may also need special medicine to help remove extra potassium from the body and keep it from coming back. This may include: Water pills (diuretics) help rid your body of extra potassium. They work by making your kidney create more urine. Potassium is normally removed through urine.
What happens if you have high potassium levels?
If hyperkalemia comes on suddenly and you have very high levels of potassium, you may feel heart palpitations, shortness of breath, chest pain, nausea, or vomiting. Sudden or severe hyperkalemia is a life-threatening condition. It requires immediate medical care.
Is potassium bad for your heart?
Potassium helps your nerves and muscles, including your heart, work the right way. But too much potassium in your blood can be dangerous . It can cause serious heart problems.
What is hyperkalemia in the emergency department?
Abstract. Hyperkalemia is a common electrolyte disorder observed in the emergency department. It is often associated with underlying predisposing conditions, such as moderate or severe kidney disease, heart failure, diabetes mellitus, or significant tissue trauma. Additionally, medications, such as inhibitors of the renin-angiotensin-aldosterone ...
What to do with hyperkalemia in ED?
In all patients presenting with acute hyperkalemia to the ED, a critical review of current medications should be performed for drugs that could cause hyperkalemia. Temporarily discontinuing inhibitors of the renin-angiotensin-aldosterone system should be considered, and a search for and treatment of any underlying condition leading to hyperkalemia should be performed. If the risk of hyperkalemia remains an ongoing issue, dietary instructions regarding low- potassium foods and avoidance of potassium -rich foods should be given to patients with moderate and severe kidney disease. Timing of further monitoring of potassium concentration, and whether as an in-patient or as an out-patient will depend upon the severity of the hyperkalemia, the severity of its manifestations, the likelihood of rebound, and the patient’s overall clinical context and response to treatment. A recent retrospective study performed at a large academic ED found that mortality of patients with hyperkalemia was dramatically lower in the group whose potassium concentration was normalized (<5.5 mmol/l) during the ED stay compared to those whose potassium concentration remained elevated [ 79 ]. These data indicate that treatment in the ED or intensive/intermediate care units of patients with acute hyperkalemia until normalization of potassium concentrations might be preferable.
Why does hyperkalemia occur?
Usually, hyperkalemia develops because of increased intake, decreased excretion, or because of a shift of potassium from the intracellular to the extracellular compartment. Increased intake alone is unlikely to cause hyperkalemia because of the excess capacity of the healthy kidney to excrete potassium [ 19 ].
What are the risk factors for hyperkalemia?
Overall, major risk factors for development of hyperkalemia are worsening of kidney function as expressed by a lower estimated glomerular filtration rate, a higher baseline potassium concentration, or the presence of comorbidities, including diabetes mellitus, heart failure, and coronary artery disease [ 20, 21 ].
What is the ECG for hyperkalemia?
The ECG is a mainstay in managing hyperkalemia. Membrane stabilization by calcium salts and potassium -shifting agents, such as insulin and salbutamol, is the cornerstone in the acute management of hyperkalemia. However, only dialysis, potassium -binding agents, and loop diuretics remove potassium from the body.
When to use point of care testing?
Use of point-of-care testing should be considered in patients in whom hyperkalemia is clinically suspected based on symptoms or ECG, and in those at high risk for hyperkalemia (e.g., patients who receive dialysis treatment). The rapid availability of results may permit more rapid initiation of treatment.
Is hyperkalemia mild or severe?
There is not a common and standardized definition for grad ing of the severity of hyperkalemia as mild, moderate, or severe; potassium concentrations vary depending on whether serum or plasma potassium was analyzed, with serum potassium concentrations usually being higher than plasma concentrations [ 3–5 ].
Treatment
- Hyperkalemia occurs when you have too much potassium in your blood. Because hyperkalemia is a sign that something else is going on in your body, treatment depends on what's causing it and whether the level of potassium in your blood is judged to be an emergency or not. Methods of treatment may include intravenous therapies, dialysis, diuretics, pot...
Mechanism of action
- Intravenous (IV) calcium immediately counteracts the effects that high potassium levels have on your cell membranes and stabilizes the electrical systems in your heart, nerves, and muscles. Because the effects only last up to 60 minutes, to work most effectively, it needs to be combined with IV insulin and glucose, which help push the potassium back into your cells. Potassium-rem…
Overview
- Also known as water pills, diuretics work by increasing the amount of potassium your body excretes into your urine. They're prescribed for both emergency and non-emergency hyperkalemic situations if you have normal or mild to moderately impaired kidney function, but not for severely impaired kidney function.
Side effects
- Potential side effects of diuretics include increased urination, hypokalemia (low blood potassium levels), hyponatremia (low blood sodium levels), dizziness, headaches, dehydration, cramps in your muscles, joint disorders, and erectile difficulties.
Usage
- RAAS inhibitors spare potassium from being excreted in your urine, the opposite of how patiromer works. They are typically prescribed to people with heart failure, diabetes, and chronic kidney disease.
Medical uses
- Albuterol isn't used often and never by itself. But, it can work to lower potassium levels in people whose symptoms of hyperkalemia aren't getting any better despite treatment with calcium and insulin with glucose or for whom dialysis isn't an option.
Administration
- It's typically administered with a nebulizer, which takes saline and albuterol and sprays it into a fine mist that you breathe in. If you can't tolerate a nebulizer, it can be administered through an IV instead. Using albuterol can make you shaky and make your heart beat faster.
Diet
- You can lower your intake of potassium by avoiding or decreasing your intake of these foods and concentrating on foods that are low in potassium. Green beans, cabbage, broccoli, apples, grapes, strawberries, cheese, eggs, fresh chicken, and fresh pork are all safe to eat when you're on a low-potassium diet. Your doctor may recommend that you work with a dietician to help you plan you…
Symptoms
- Signs of a hyperkalemic emergency include weakness or paralysis of your muscles and heart abnormalities that can be picked up on an electrocardiogram (ECG), such as the electrical impulses in the heart being affected or a heart arrhythmia (abnormal heartbeat). Even if you don't have any symptoms of hyperkalemia, if your blood potassium level is greater than 6.5 mEq/ L, it …
Diagnosis
- Your doctor will monitor your heart closely, most likely performing multiple ECGs and testing your blood periodically to make sure your potassium levels have gone down and that your glucose levels stay normal. If you're on any medications that contribute to high potassium levels, your doctor may have you discontinue them, at least temporarily.