Hyperkalemia detected (adults)
Serum K+ 5.5 mmol/L or higher. Mild 5.5-5.9, moderate 6.0-6.4, severe 6.5 mmol/L or higher.
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Emergency MedicineEmergency
Hyperkalemia Emergency Management (Adults)
Hyperkalemia Emergency Management (Adults): Hyperkalemia detected (adults) → Adults only. Cardiac arrest or peri-arrest: start ALS now → Confirm and ass...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning Adults only. Cardiac arrest or peri-arrest: start ALS now
Children: use a paediatric weight-based protocol.
- Arrest: calcium chloride 10% 10 mL IV bolus
- Arrest: insulin 10 units with glucose 25 g IV. Severe acidosis or renal failure: sodium bicarbonate 8.4% 50 mL IV (not mixed with calcium chloride)
- Refractory arrest: call renal or ICU team for dialysis or ECMO during CPR
03Action Confirm and assess
Assess airway, breathing and circulation. Do not delay treatment for a repeat sample if the ECG shows changes or K+ is 6.5 mmol/L or higher.
- 12-lead ECG now; continuous cardiac monitoring if K+ 6.5 mmol/L or higher or ECG changes
- Blood gas K+ while the lab result is pending; check glucose and creatinine
- Suspected pseudohyperkalemia (haemolysis, fist clenching, tight tourniquet, very high WBC or platelets): repeat from a large vein with fast analysis
- Review drugs: ACE inhibitor, ARB, MRA, K+-sparing diuretic, NSAID, trimethoprim, heparin, calcineurin inhibitor, beta-blocker, K+ supplements, digoxin
04Warning On digoxin: suspect toxicity? Give digoxin Fab
Check the digoxin level. Hyperkalemia with suspected digoxin toxicity is an indication for Fab.
- ECG changes: do not delay IV calcium; digoxin is a caution, not a contraindication
- Digoxin immune Fab: dose with a toxicologist or Poisons Information Centre 13 11 26 (AU)
- After Fab, K+ can fall fast: recheck K+ often
05Decision ECG changes of hyperkalemia?
Peaked T waves, flat or absent P waves, long PR, wide QRS, bradycardia, sine wave, VT or VF.
- If Yes
06Action ECG changes: give IV calcium now
Protects the heart. Does not lower K+. Effect lasts 30-60 min. Adult doses.
- Calcium gluconate 10% 30 mL IV over 10 min
- Peri-arrest: calcium chloride 10% 10 mL IV over 5 min, large or central vein
- Repeat the dose if ECG changes persist, or if the effect wears off and K+ is still high
- Then start insulin-glucose (next step)
07Action Shift K+ into cells: insulin-glucose
Give if K+ 6.5 mmol/L or higher or ECG changes. Consider if K+ 6.0-6.4 mmol/L. Adult doses. Check blood glucose first. DKA or HHS: follow the DKA protocol instead. IV sodium bicarbonate: not routine.
- Soluble insulin 10 units with glucose 25 g (50 mL of 50%) IV over 5-15 min into a large vein
- Glucose below 7.0 mmol/L before treatment: then glucose 10% at 50 mL/h for 5 h
- K+ 6.5 mmol/L or higher: add salbutamol 10-20 mg nebulised (10 mg if ischaemic heart disease; caution in tachyarrhythmia); never alone
- Check glucose at 0, 30, 60, 90 and 120 min, then hourly to 6 h; highest risk in kidney failure
08Action Remove K+ from the body
Binders act over hours. Give them with, not instead of, insulin-glucose. DKA or HHS: binders not studied; follow the DKA protocol.
- Sodium zirconium cyclosilicate 10 g orally three times daily, up to 72 h (K+ 6.5 or higher: give; 6.0-6.4: consider)
- Or patiromer 8.4 g orally once daily (K+ 6.0 mmol/L or higher)
- Polystyrene sulfonate resins: not for routine acute use
- Loop diuretic only if passing urine and not volume depleted
09Warning Call renal or ICU team early: dialysis?
K+ 6.5 mmol/L or higher, refractory K+, oliguric AKI, advanced CKD or on dialysis.
- On haemodialysis with K+ 6.5 mmol/L or higher: urgent dialysis; medical therapy until it starts
- Uncontrolled K+ despite medical therapy, mainly with oliguric AKI or advanced CKD: dialysis
- Airway, breathing, circulation or conscious-level problem: ICU
10Action Monitor K+, glucose and ECG
Shift therapy wears off in hours. Watch for rebound.
- K+ at 1, 2, 4, 6 and 24 h after treatment (moderate or severe)
- Continuous cardiac monitoring if K+ 6.5 mmol/L or higher or ECG changes
- K+ still 6.0 mmol/L or higher 2 h after insulin-glucose: consider a repeat dose and seek specialist advice
- Glucose checks for 6 h after insulin
11Action Treat the cause and prevent recurrence
- Stop or hold K+-raising drugs; review the risk before restarting them
- Treat AKI, hypovolaemia, acidosis, hyperglycaemia and urinary retention; consider adrenal insufficiency
- Low-K+ diet only after other causes are addressed
- Arrange a K+ check after discharge
12Outcome K+ controlled
K+ below 5.5 mmol/L, ECG normal, cause treated, K+ recheck arranged.
If No13Decision Normal ECG: is K+ 6.0 mmol/L or higher?
A normal ECG does not remove the risk of arrhythmia.
- If Yes
- K+ 6.0 or higher
14Action Normal ECG, K+ 6.0 mmol/L or higher: lower K+ now
IV calcium is not needed while the ECG stays normal. DKA or HHS: follow the DKA protocol instead.
- K+ 6.5 mmol/L or higher: insulin-glucose plus salbutamol; continuous cardiac monitoring
- K+ 6.0-6.4 mmol/L: consider insulin-glucose; treat the cause
- Give IV calcium at once if ECG changes appear
- Then continue: K+ binder, renal or ICU call if K+ 6.5 mmol/L or higher, and monitoring (the steps after insulin-glucose)
- Path rejoins step 07Shared downstream outcome
If No- K+ 5.5-5.9
15Action Normal ECG, K+ 5.5-5.9 mmol/L: treat the cause
Mild hyperkalemia. IV calcium and insulin-glucose are not needed.
- Stop K+ supplements and K+ in IV fluids
- Hold or reduce K+-raising drugs where safe
- Treat AKI, dehydration or acidosis
- Recheck K+ within 3 days; sooner if unwell or AKI
- Path rejoins step 11Shared downstream outcome
Guideline Source
UK Kidney Association Clinical Practice Guideline: Treatment of Acute Hyperkalaemia in Adults (October 2023)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only: children need a paediatric weight-based protocol
- Cardiac arrest: follow ALS; this pathway lists only the hyperkalemia-specific steps
- Hospital stock of potassium binders varies
- Does not cover long-term outpatient management of chronic hyperkalemia
Contraindicated Populations
children (use a paediatric weight-based protocol)
Applicable Regions
AUUSEUGlobal
AU: Poisons Information Centre 13 11 26. Sodium zirconium cyclosilicate (Lokelma) and patiromer (Veltassa) are on the ARTG; hospital stock varies.
EU: ERC special-circumstances guidance takes a similar approach.
US: K+ in mEq/L equals mmol/L. Glucose 7.0 mmol/L is about 126 mg/dL.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Hyperkalemia Emergency Management (Adults)?
The Hyperkalemia Emergency Management (Adults) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on UK Kidney Association Clinical Practice Guideline: Treatment of Acute Hyperkalaemia in Adults (October 2023).
What guideline is the Hyperkalemia Emergency Management (Adults) based on?
This algorithm is based on UK Kidney Association Clinical Practice Guideline: Treatment of Acute Hyperkalaemia in Adults (October 2023).
What are the limitations of the Hyperkalemia Emergency Management (Adults)?
Known limitations include: Adults only: children need a paediatric weight-based protocol; Cardiac arrest: follow ALS; this pathway lists only the hyperkalemia-specific steps; Hospital stock of potassium binders varies; Does not cover long-term outpatient management of chronic hyperkalemia. Individual patient factors may require deviation from these recommendations.
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