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History
Presenting symptoms
Symptom profile
Neuromuscular
Generalized weakness
Paresthesias
Flaccid paralysis
Cardiopulmonary
Palpitations
Chest discomfort
Dyspnea
Neuro
Lightheadedness
Syncope
OPQRST
Onset
Time of onset
Rapid onset minutes to hours
Provocation and palliation
Recent missed dialysis
Recent medication change
Quality
Weakness
Paresthesia
Region and radiation
Proximal weakness
Ascending weakness
Severity
Functional limitation
Near syncope or syncope
Timing
Persistent
Intermittent episodes
Associated context
Triggering events
Recent illness
Vomiting or diarrhea
Dehydration
Baseline status
Known chronic kidney disease
Usual potassium range
Prior episodes
Prior hyperkalemia treatment
Prior arrhythmia history
Alarm Features
Immediate life threats
High risk features
Potassium 6.5 mmol/L or higher
Any ECG change consistent with hyperkalemia
Ventricular arrhythmia
Bradycardia with hypotension
Syncope
Progressive paralysis
Vital sign danger thresholds
Dangerous physiology
Systolic blood pressure under 90 mmHg
Heart rate under 40 per minute with symptoms
Oxygen saturation under 90 percent
Escalation triggers
Resuscitation activation
Wide complex rhythm
Unstable bradycardia
Refractory hypotension
Potassium rising despite temporizing therapy
Medications
Hyperkalemia provoking agents
Current exposures
ACE inhibitor
ARB
Mineralocorticoid receptor antagonist
Potassium supplements
NSAID
Trimethoprim sulfamethoxazole
Heparin
Calcineurin inhibitor
Recent changes
Dose increase in RAAS blockade
New potassium supplement
Treatment relevant medications
Beta agonist tolerance risks
Nonselective beta blocker
Significant tachyarrhythmia history
Digoxin
Toxicity concern
Avoid IV calcium if digoxin toxicity strongly suspected
Allergy and contraindication screen
Contraindications
Severe volume overload for large dextrose loads
Severe asthma contraindications for beta agonist
Bowel obstruction history for potassium binders
Diet
Potassium intake pattern
Dietary contributors
Salt substitutes containing potassium
High potassium foods increase
High potassium nutrition supplements
Hydration and renal perfusion
Intake and losses
Low oral intake
Vomiting
Diarrhea
Review of Systems
Cardiopulmonary
Symptoms
Palpitations
Chest pain
Dyspnea
Syncope
Neuromuscular
Symptoms
Weakness
Paresthesias
Paralysis
Infectious and metabolic
Symptoms
Fever
Oliguria
Polyuria
Polydipsia
Collateral History and Family History
Collateral and reliability
Sources
Family or caregiver report
Dialysis unit report
Medication list verification
Family history
Inherited and early disease
Sudden cardiac death
Inherited renal disease
Risk Factors
Renal and endocrine
Comorbid risks
Chronic kidney disease (N18.9)
End stage kidney disease (N18.6)
Diabetes mellitus (E11.9)
Adrenal insufficiency (E27.40)
Tissue breakdown and shifts
Redistribution risks
Rhabdomyolysis (M62.82)
Tumor lysis syndrome (E88.3)
Hemolysis
Metabolic acidosis (E87.2)
Iatrogenic and device related
Access and procedures
Missed hemodialysis session
Recent transfusion
High potassium IV fluids
Differential Diagnosis
Life threatening
Hyperkalemia with cardiotoxicity (E87.5)
ECG changes
Bradyarrhythmia
Ventricular arrhythmia
Acute kidney injury (N17.9)
Oliguria
Rising creatinine
Tumor lysis syndrome (E88.3)
Cancer therapy recent
Hyperphosphatemia
Rhabdomyolysis (M62.82)
Myalgias
Very high creatine kinase
Common
Chronic kidney disease progression (N18.9)
Medication accumulation
Dietary potassium load
Medication induced hyperkalemia (E87.5)
RAAS blockade
Trimethoprim
Metabolic acidosis related shift (E87.2)
Diabetic ketoacidosis (E10.10)
Lactic acidosis (E87.2)
Less common
Hypoaldosteronism (E27.40)
Type 4 renal tubular acidosis (E87.5)
Diabetic nephropathy association
Pseudohyperkalemia
Hemolyzed sample
Severe thrombocytosis
Severe leukocytosis
Past Medical History
Renal and cardiac history
Baseline conditions
Chronic kidney disease stage
Dialysis modality
Heart failure (I50.9)
Coronary artery disease (I25.10)
Prior arrhythmias
Atrial fibrillation (I48.91)
Ventricular tachycardia history
Procedures and devices
Implanted or access devices
AV fistula
Dialysis catheter
Pacemaker or ICD
Physical Exam
General and vitals
Overall status
Toxic appearance
Altered mental status
Perfusion
Hypotension
Cool extremities
Cardiovascular
Rhythm and perfusion
Bradycardia
Irregular rhythm
Signs of shock
Respiratory
Work of breathing
Tachypnea
Pulmonary edema signs
Neuromuscular
Strength and tone
Proximal weakness
Decreased reflexes
Flaccid paralysis
Volume status
Fluid assessment
Peripheral edema
Dry mucous membranes
Lab Studies
Core confirmation and severity
Potassium verification
Repeat potassium urgent
Plasma sample if pseudohyperkalemia suspected
Hemolysis index review
Renal function
Creatinine
Urea
Acid base and shift drivers
Venous blood gas
Bicarbonate
Lactate
Etiology focused labs
Tissue breakdown
Creatine kinase
Phosphate
Endocrine
Glucose
Beta hydroxybutyrate
Cortisol if adrenal insufficiency concern
Pitfalls and limitations
False elevation patterns
Hemolyzed specimen
Delayed processing
Thrombocytosis
Leukocytosis
Imaging
Scoring Systems
Test selection logic
Not applicable scoring systems
Use clinical severity
MRI
Indications
Not routine for isolated hyperkalemia
Neurologic deficit alternate diagnosis pathway
CT
Indications
Not routine for isolated hyperkalemia
CT abdomen pelvis if obstruction or ischemia suspected
Ultrasound
Renal and volume assessment
POCUS bladder volume for retention
IVC assessment for volume status limitations
Special Tests
Bedside tests
Point of care monitoring
Continuous cardiac monitoring
Point of care glucose during insulin therapy
Diagnostic clarification
Pseudohyperkalemia workup
Repeat sample without tourniquet
Rapid processing
Plasma potassium comparison
ECG
Indications and timing
ECG workflow
Immediate ECG for suspected hyperkalemia
Repeat ECG after temporizing therapy
Hyperkalemia patterns
Early patterns
Tall peaked T waves
Shortened QT interval
Progressive patterns
PR prolongation
P wave flattening
QRS widening
Pre arrest patterns
Sine wave
Ventricular fibrillation
Asystole
Mimics and pitfalls
Differential patterns
STEMI mimics
Bundle branch block baseline
Assessment
Working diagnosis and severity
Hyperkalemia (E87.5)
Mild
Potassium 5.5 to 5.9 mmol/L
No ECG changes
Moderate
Potassium 6.0 to 6.4 mmol/L
No ECG changes or minimal changes
Severe
Potassium 6.5 mmol/L or higher
Any ECG changes
Symptoms consistent with hyperkalemia
Complications to rule out
Cardiac complications
Malignant arrhythmia
Unstable bradycardia
Renal complications
Acute kidney injury (N17.9)
Dialysis access failure
Alternative diagnoses and uncertainty
Pseudohyperkalemia
Hemolyzed sample
Thrombocytosis
Leukocytosis
Plan
First 5 minutes
Time critical stabilization
Monitor
Cardiac monitor
Defibrillator pads if unstable rhythm
Access
IV access
Two large bore IV if unstable
ECG
Immediate ECG
Repeat after interventions
Escalation
If unstable rhythm then resuscitation pathway
Early nephrology if dialysis likely
Cardiac membrane stabilization
Calcium therapy
Calcium gluconate IV 3 g
Typical adult dose
Repeat dose if persistent ECG changes
Calcium chloride IV 1 g
Prefer central line
Higher elemental calcium than gluconate
Intracellular shift therapies
Insulin dextrose
Regular insulin IV 10 units
Dextrose IV 25 g
Glucose monitoring
Check at 0 minutes
Check at 30 minutes
Check at 60 minutes
Check at 120 minutes
Beta agonist
Albuterol nebulized 10 mg
Tachycardia risk monitoring
Sodium bicarbonate
Indication
Metabolic acidosis with hyperkalemia
Not reliable in absence of acidosis
Dose example
Sodium bicarbonate IV 50 mmol
Repeat based on pH response
Potassium removal
Diuretics
Furosemide IV 40 mg
Requires urine output
Potassium binders
Sodium zirconium cyclosilicate oral 10 g
Patiromer oral 8.4 g
Delayed onset
Not sole therapy in severe cases
Use with temporizing measures
Sodium polystyrene sulfonate
Use caution
GI adverse event risk
Dialysis
Indications
Severe hyperkalemia with ECG changes
Refractory hyperkalemia after temporizing therapy
End stage kidney disease with missed dialysis
Etiology directed management
Medication adjustments
Hold RAAS blockade temporarily
Stop potassium supplements
Treat underlying cause
DKA pathway if present
Rhabdomyolysis pathway if present
Tumor lysis pathway if present
Reassessment loop
Serial monitoring
Repeat potassium at 30 to 60 minutes after temporizing therapy
Repeat ECG after calcium and shift therapy
Repeat glucose per insulin protocol
Failure triggers
Potassium not decreasing
Recurrent ECG changes
Rebound hyperkalemia
Disposition
ICU criteria
High acuity disposition
Any malignant arrhythmia
Unstable bradycardia
Sine wave pattern
Need for urgent dialysis with instability
Inpatient admission criteria
Admission indications
Potassium 6.0 mmol/L or higher with significant comorbidity
Acute kidney injury
Need for ongoing potassium monitoring and therapy
Observation criteria
Short stay pathway
Potassium 5.5 to 5.9 mmol/L with reversible cause treated
No ECG changes
Reliable follow up and medication review
Discharge criteria
Safe discharge features
Potassium normalized or clearly trending down to safe range
No ECG changes
Cause addressed and medication plan updated
Follow up within 24 to 72 hours
Reliable access to labs and care
Discharge Instructions
Copy discharge instructions
Diagnosis summary
High potassium level in the blood
This can affect the heart rhythm and muscles
Medications
Take medicines exactly as prescribed
Do not restart any stopped medicines unless told
Diet
Avoid salt substitutes with potassium
Limit high potassium foods until follow up
Follow up
Repeat blood test within 24 to 72 hours
Follow up with primary care or nephrology
Return to emergency now
Chest pain
Fainting
New or worsening weakness
Palpitations
Shortness of breath
References
Guidelines and key sources
Evidence base
Kidney Disease Improving Global Outcomes
CKD guideline update 2024
Hyperkalemia management in CKD sections
American Heart Association
ACLS guidelines update 2020
Bradycardia and cardiac arrest algorithms
UK Kidney Association
Hyperkalemia guideline 2022
Emergency management pathways
National Kidney Foundation
KDOQI guidance
CKD and potassium management
European Resuscitation Council
Resuscitation guidelines 2021
Reversible causes including hyperkalemia
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.