› Immediate stabilization workflow
› Cardiac monitor if potassium concern or instability
› IV access criteria
› Two large bore IVs if shock or severe hyperkalemia
› One IV if stable
› Oxygen if saturation less than 92 percent
› Point of care glucose if altered mental status
› If ECG hyperkalemia pattern, initiate temporizing therapy and resuscitation escalation
› ! Acute Kidney Injury (Pre-renal) → › ! Acute Kidney Injury (ATN) → › Acute Kidney Injury (Post-renal) → › Rhabdomyolysis → › Hyperkalemia → › Urinary Retention → › Minimum initial bundle
› Repeat creatinine and electrolytes if outpatient abnormal
› Urinalysis and microscopy early
› Bladder scan early if low urine output or LUTS
› Renal ultrasound if obstruction concern or unclear etiology
› Sepsis evaluation bundle if infection suspected
› Hemodynamics and kidney protection
› If hypovolemia likely, isotonic crystalloid bolus 500 mL to 1000 mL then reassess
› If heart failure congestion likely, cautious diuresis strategy
› Stop nephrotoxins when possible
› NSAIDs
› ACE inhibitor
› ARB
› Metformin if significant AKI or hypoperfusion
› Hyperkalemia temporizing therapy when indicated
› Calcium gluconate 10 percent 10 mL IV over 2 to 5 minutes if ECG changes
› Regular insulin 10 units IV with dextrose 25 g IV
› Nebulized salbutamol 10 mg to 20 mg
› Sodium bicarbonate 50 mmol IV if severe acidosis and appropriate context
› Potassium removal
› Loop diuretic if urine output present and volume status allows
› Potassium binder if clinically appropriate and local protocol dependent
› Suspected urinary obstruction
› Foley catheter if retention likely and no contraindication
› Urology involvement if difficult catheter or obstructing stone with infection concern
› Suspected rapidly progressive glomerulonephritis
› Nephrology urgent involvement
› Avoid delays for serologies and urine microscopy review
Monitoring and reassessment loop
› Reassessment cadence
› Repeat vitals within 30 to 60 minutes after fluids or diuresis
› Repeat potassium within 1 to 2 hours after temporizing therapy
› Strict intake and output
› Daily weight if admitted
› Repeat creatinine within 6 to 24 hours depending on severity
Consultation and referral logic
› Who and when
› Nephrology same day for KDIGO stage 2 or 3
› Nephrology same day for suspected glomerulonephritis syndrome
› Nephrology same day for refractory electrolyte derangements
› Urology same day for obstruction with infection concern
› ICU consult for shock, severe pulmonary edema, or severe hyperkalemia with instability
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