Hyperkalemia Emergency Management (AHA 2025)

Algorithm Steps

1. ▶

   Start

   START: Hyperkalemia Detected

   Serum K+ >5.5 mEq/L (or elevated above normal)

   1. ●

      Action

      Confirm and Assess

      Rule out pseudohyperkalemia, assess urgency

      • Check for hemolysis, difficult draw, high WBC/platelets
      • Repeat K+ if unexpected result
      • Get 12-lead ECG immediately
      • Review medications (ACE-I, ARB, K-sparing diuretics, NSAIDs)
      1. ◆

         Decision

         ECG Changes Present?

         Evaluate for cardiac toxicity

         • EARLY (K+ 5.5-6.5): Peaked/tall T waves
         • MODERATE (K+ 6.5-7.5): Prolonged PR, flattened P waves
         • SEVERE (K+ >7.5): Wide QRS, sine wave pattern, VF risk
         • Note: ECG changes don't always correlate with K+ level
         1. ⚠

            Warning

            ECG Changes = EMERGENCY

            Immediate cardiac membrane stabilization

            1. ●

               Action

               STEP 1: Calcium (Cardiac Protection)

               Immediate IV calcium - stabilizes myocardium

               • Calcium gluconate 10% 10-20 mL IV over 2-3 min
               • OR Calcium chloride 10% 5-10 mL IV (central line preferred)
               • Onset: 1-3 minutes
               • Duration: 30-60 minutes
               • May repeat in 5-10 min if ECG not improved
               • ⚠️ Caution in digoxin toxicity (give slower, 20-30 min)
               1. ●

                  Action

                  STEP 2: Shift K+ Into Cells

                  Temporarily lowers serum K+

                  • INSULIN + GLUCOSE:
                  • - Regular insulin 10 units IV
                  • - PLUS D50W 25-50 mL IV (if glucose <250)
                  • - Onset: 15-30 min, Duration: 4-6 hr
                  • - Monitor glucose q1h x 4-6 hrs
                  • BETA-AGONIST (Albuterol):
                  • - 10-20 mg nebulized over 10 min
                  • - Onset: 30 min, Duration: 2-4 hr
                  • - Additive to insulin
                  • SODIUM BICARBONATE:
                  • - 50-100 mEq IV if acidotic (pH <7.2)
                  • - Less effective if no acidosis
                  1. ◆

                     Decision

                     Dialysis Needed?

                     Consider urgency and indication

                     • DIALYSIS INDICATIONS:
                     • - Refractory to medical therapy
                     • - Oliguric/anuric renal failure
                     • - Severely elevated K+ (>7) with symptoms
                     • - ECG changes persist despite treatment
                     1. ⚠

                        Warning

                        Emergent Dialysis

                        Contact nephrology immediately

                        • Hemodialysis preferred (fastest K+ removal)
                        • CRRT if hemodynamically unstable
                        • Temporary dialysis catheter if no access
                        • Continue medical therapy while arranging
                        1. ●

                           Action

                           Monitoring

                           Close follow-up required

                           • Repeat K+ in 1-2 hours after treatment
                           • Continuous cardiac monitoring if ECG changes
                           • Monitor glucose q1h x 6hr after insulin
                           • Re-treat if K+ rises or ECG changes recur
                           1. ●

                              Action

                              Address Underlying Cause

                              Prevent recurrence

                              • Stop offending medications
                              • Treat AKI/CKD
                              • Correct acidosis
                              • Address diet (high K+ foods)
                              • Nephrology follow-up if needed
                              1. ✓

                                 Outcome

                                 K+ Normalized

                                 Continue monitoring and prevention

                                 • Target K+ <5.5 mEq/L
                                 • Maintain dietary potassium restriction if needed
                                 • Consider chronic potassium binder if recurrent
                                 • Medication review and adjustment
                     2. ●

                        Action

                        STEP 3: Eliminate K+ From Body

                        Definitive removal

                        • LOOP DIURETICS (if adequate renal function):
                        • - Furosemide 40-80 mg IV
                        • POTASSIUM BINDERS:
                        • - Patiromer (Veltassa) 8.4g PO - onset 7 hrs
                        • - Sodium zirconium cyclosilicate (Lokelma) 10g PO - onset 1 hr
                        • - SPS/Kayexalate 15-30g PO (avoid in bowel issues)
                        • DIALYSIS (definitive):
                        • - Indicated for severe/refractory hyperkalemia
                        • - ESRD or AKI with oliguria
                        • - Removes 25-50 mEq K+ per hour
         2. ◆

            Decision

            Potassium Level

            Severity without ECG changes

            1. ●

               Action

               K+ 5.5-6.4 (Moderate)

               Lower acuity but still treat

               • Remove K+ from IV fluids and diet
               • Stop offending medications
               • May use potassium binders if stable
               • Consider shift therapy if rising
            2. ●

               Action

               K+ ≥6.5 (Severe)

               Urgent treatment even without ECG changes

               • Consider calcium for protection
               • Proceed to shift therapy
               • Prepare for dialysis if renal failure