ICU Map

Severe Hyperkalemia Emergency Management

From emergent cardiac membrane stabilization to intracellular shifting, elimination, and dialysis triggers.

RecognizeAssessDecideDifferentialInterveneReassess
Severe Hyperkalemia (K+ > 6.0 mEq/L) / ECG Instability
Assessment StepObtain immediate 12-lead ECG & continuous telemetryExplore Topic
Check for peaked T waves, PR prolongation, loss of P waves, QRS widening (>120 ms), and sinusoidal pattern. ECG changes define acute cardiac emergency.
Clinical ActionPhase 1: Stabilize cardiac membrane immediately (if ECG changes or K+ > 6.5)
Administer IV Calcium Chloride 10% (1 g = 10 mL via central/reliable line) or IV Calcium Gluconate 10% (3 g = 30 mL peripheral). Onset in 1–3 min; repeat in 5 min if ECG changes persist.
Clinical ActionPhase 2: Shift potassium intracellularly (Rapid temporary lowering)
Give Regular Insulin 10 Units IV with 50 mL D50W (25 g glucose; check fingerstick glucose q1h). Add Nebulized Albuterol 10–20 mg (beta-2 receptor activation). Lowers K+ by 0.5–1.2 mEq/L within 30–60 min.
Decision PointPhase 3: Eliminate potassium from the total body
Shifting is temporary (rebound occurs at 2–4 hours). Total body excretion must be initiated simultaneously.
Differential Branches (3)
1Branch
Clinical ActionPreserved Urine Output: IV Loop Diuretics (Furosemide 40–80 mg)
Promotes kaliuresis in distal nephron. Maintain intravascular volume with balanced crystalloid if not fluid overloaded.
2Branch
Clinical ActionOral Binders: Sodium Zirconium Cyclosilicate (Lokelma 10 g) or Patiromer
Binds potassium in GI tract. Avoid Sodium Polystyrene Sulfonate (Kayexalate) in sorbitol due to bowel necrosis risk.
3Branch
Critical AlertOliguric AKI / Refractory Hyperkalemia: Urgent Hemodialysis / CRRTExplore Topic
Most rapid and definitive method for total body potassium clearance (clears 25–40 mEq/h). Trigger immediately if medical therapy fails.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • Sine wave ECG pattern or severe bradyarrhythmia — indicates imminent cardiac arrest; give immediate IV calcium chloride, push D50 + insulin, and prepare for emergency cardiac pacing/CPR.
  • Severe delayed hypoglycemia following IV insulin administration — monitor fingerstick blood glucose every hour for at least 4–6 hours post-treatment.

Related Bedside Clinical Problems (14)

Bedside Presentations
New Tachycardia & Tachyarrhythmias

Algorithmic triage of acute heart rates > 100–150 bpm: stability screen (immediate cardioversion if unstable), narrow vs wide QRS differentiation, Brugada VT rules, and sinus tachycardia etiology search.

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New Bradycardia & Conduction Blocks

Acute bradyarrhythmia management: identifying hemodynamic instability, distinguishing sinus node arrest vs high-grade AV block, medical chronotropic support (atropine, epinephrine), and emergent pacing.

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Rapidly Progressive Weakness / Impending Ventilatory Failure

Bedside assessment and airway decision-making in rapidly ascending or fatiguable weakness risking ventilatory pump failure.

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Linked Deep-Dive Topics (3)

Reference Knowledge
Severe Hyperkalemia in Critical Illnessrenal

Nernst resting potential mechanics, ECG progression, the 3-step resuscitation framework (Stabilize, Shift, Eliminate), and post-dialysis rebound kinetics.

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Acute Kidney Injury in Critical Carerenal

Sepsis-AKI microcirculatory decoupling, KDIGO staging, Furosemide Stress Test (FST), urine microscopy, and the AEIOU dialysis threshold framework.

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Continuous Renal Replacement Therapy (CRRT)renal

Principles of convection vs diffusion, filtration fraction, delivered effluent dosing (20–25 mL/kg/h), Regional Citrate Anticoagulation, and citrate toxicity.

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