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Immediate stabilization
Initial priorities
Resuscitation bay for K >= 6.5 mmol/L
Resuscitation bay for any hyperkalemia with ECG changes
Resuscitation bay for any hyperkalemia with hemodynamic instability
Cardiac monitor and defibrillation pads
Continuous ECG monitoring
Frequent blood pressure monitoring
IV access
Two large bore peripheral IV lines
Consider intraosseous access if IV delay
Point-of-care glucose
Baseline before insulin therapy
Repeat q 30 to 60 minutes after insulin
Early ECG
Repeat ECG after membrane stabilization
Repeat ECG for any rhythm change
Time-critical decision points
If malignant arrhythmia or cardiac arrest, hyperkalemia ACLS pathway
Immediate calcium
Immediate potassium shift therapies
If ECG changes present, do not delay treatment awaiting repeat potassium
Treat while confirming with repeat non-hemolyzed sample
Treat while evaluating for pseudohyperkalemia
If renal failure or refractory hyperkalemia, early nephrology
Dialysis planning during initial stabilization
Concurrent temporizing therapy while arranging dialysis
Hemodynamic and monitoring targets
Monitoring targets
Stable perfusion
Systolic blood pressure appropriate for age and baseline
No ongoing dysrhythmia
Glucose safety during insulin therapy
Glucose 6 to 10 mmol/L target range during treatment
Dextrose support if glucose trending down
Potassium reassessment schedule
Repeat potassium 30 to 60 minutes after temporizing therapy
Repeat potassium q 1 to 2 hours until stable trend
Key concepts
Core pathophysiology
Cardiac membrane depolarization from elevated extracellular potassium
Conduction slowing and bradyarrhythmias
Ventricular dysrhythmias and asystole risk
ECG severity may not correlate with serum potassium
Dangerous ECG changes can occur at moderate potassium levels
Severe hyperkalemia can occur with minimal ECG change
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.