Hyperkalemia

Can be an acutely life-threatening medical emergency Can be the result of 1 of 4 mechanisms Increased potassium intake Enhanced potassium absorption Impaired potassium excretion Potassium shifts Out of cells into the serum Multiple possible etiologies Pseudohyperkalemia Increased potassium intake and absorption Potassium supplements Impaired renal excretion Drugs: ace ard nsaids cox2inhibitors, K sparing diuretics Hypoaldosteronism Transcellular shifts Rhabdomyolisis Cellular injury Thrombocytosis Leukocytosis DIAGNOSIS S/Sx: depend on level AND RATE of increase Primary Symptoms ECG changes HYPERKALEMIA = ECG Peaked T-waves Loss of P-waves, decreasing R wave precordial leads QRS widening Sine-wave pattern: progresses to V-fib or asystole Cardiac dysrhythmias Second- and third-degree heart block Wide-complex tachycardia Ventricular fibrillation Asystole Neurologic dysfunction (usually nonspecific) Muscle cramps, weakness Paralysis, paresthesias Tetany Focal neuro deficits Labs Serum electrolyte levels BUN/Cr CBC

ECG Mild (<6.0 mEg/L) [<6.0 mmol/L] T tall and tented P widens and loses height Prolonged PR interval QRS may begin widening Severe (>6.0 mEg/L) [>6.0 mmol/L] Further or first QRS widening Second part of QRS may become notched or slurred Further P widening, flattening, and PR prolongation Widened QRS may merge with tall, peaked T waves to produce sine wave TREATMENT STRATEGIES Antagonism of cardiac effects Calcium CL or gluconate CA+ ONLY IF WIDE QRS Redistribution of K+ into cells Glucose + Insulin K drop 1.0mEq in 1 hour Sodium Bicarb ONLY IF ACIDOTIC Beta agonists Removal of K+ from body Acute situations Exchange resins Dialysis Diuretics (for short term tx, chronic disease) Mineralocorticoids (for chronic disease) 0.1 to 0.3 mg/day of fludrocortisone ACUTE TREATMENT IV, monitor Mild Hyperkalemia: K = 5.5-6.5 mEq/L [5.5-6.5 mmol/L] EKG WNL Treatment Resonium 15-30 g PO OR 50 g in 200 cc H2O retention enema IV furosemide + NaCl bolus K+ diuresis , if renal function suitable Moderate Hyperkalemia: K = 6.5-7.5 mEq/L [6.5-7.5 mmol/L] EKG w/ changes (i.e. peaked T-waves) Treatment Resonium 20 g PO OR

50 g in 200 cc H2O enema Glucose + insulin Glucose 1 amp D50 (50 cc) IVP Insulin 5-10 units regular insulin IVP Can put 10 Units insulin in 500 mL of D10 NaHCO3 1 amp IV over 5 min plus 2 amps in 100 cc D5W over 30-60 min Useful if pt has metabolic acidosis Salbutamol nebs Effect lasts for 2 hrs Severe Hyperkalemia: K > 7.5 mEq/L [7.5 mmol/L] EKG with prolonged PR interval or absent P-wave, widened QRS and/or arrhythmias Treatment Calcium Ca Chloride: 5-10 cc IV slow OR Ca gluconate: 10-30 cc IV slow AVOID Ca+ if possibly Digoxin toxic Kayexalate 20g PO OR 50 g in 200 cc H2O enema Glucose + insulin Glucose 1 amp D50 (50 cc) IVP Insulin 5-10 units regular insulin IVP Can put 10 Units insulin in 500 mL of D10 NaHCO3 1 amp IV over 5 min plus 2 amps in 100 cc D5W over 30-60 min Salbutamol Nebs: 5-20 mg Effect lasts for 2 hrs Consider hemodialysis Rx underlying cause REFERENCES Corey Slovis on Emrap Electrolyte emergencies PEPID References: Gibbs, MA., Wolfson, AB, Tayal, VS.Electrolyte Disturbances In: Marx ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. Mosby-Year Book; 2002: 1727-1731 Mount, Zandi-Nejad, K.Disorders of Potassium Balance. In: Brenner & Rector's The Kidney, 2004, 7th ed 1017-1025