›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
›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
›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