What Do You Suggest?

A 61 y/o F presents to the ED for evaluation of generalized weakness, the patient is unable to provide further history as she transiently becomes unconscious before regaining consciousness during your evaluation.  

The patient is now conscious and the below EKG is obtained, what electrolyte abnormality is suggested by this EKG?  What should your management plan include?

Answer: Severe Hyperkalemia

Treatment of Severe Hyperkalemia can be broken into different groups

• Cardiac Membrane Stablization → Calcium (Calcium Chloride or Calcium Gluconate)
  • Give calcium first, lasts only 30-60 mins, repeat an EKG and re-dose if needed
  • CaCl can be given rapid IVP through a large bore IV; CaGluconate should be administered via IV infusion given risk of precipitating hypotension if given rapidly
  • CaCl has 3x the amount of Calcium than CaGluconate, standard doses are as follows:
    • CaCl: 1g IVP
    • CaGluconate: 3g IVPB
• Redistribution of K into Cells
  • Insulin/Dextrose: 10U Insulin IVP, if patient with glucose level < 350mg/dL give 2 amps of D50, if >350mg/dL, D50 not needed, recheck finger stick in 1 hour
  • Albuterol: 20mg albuterol inhaled via nebulizer
  • Sodium Bicarbonate: If acidotic given 1amp sodium bicarb to help drive K+ intracellularly
• Potassium Elimination
  • Diuretics - Lasix
  • Intravascular expansion - IVFs → enhance renal elimination
  • Kayexalate
  • Dialysis for refractory cases and/or ESRD patients
  • Sodium Bicarbonate - there is evidence to suggest NaHCO3 enhances renal elimination as well

 Happy Studying,

Doc Roddy