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Hyperkalemia in Emergency Medicine Clinical Presentation

  • Author: David Garth, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Aug 09, 2016
 

History

Hyperkalemia can be difficult to diagnose clinically because complaints may be vague. The history is most valuable in identifying conditions that may predispose to hyperkalemia.

Hyperkalemia frequently is discovered as an incidental laboratory finding.

Cardiac and neurologic symptoms predominate.

Patients may be asymptomatic or report the following:

  • Generalized fatigue
  • Weakness
  • Paresthesias
  • Paralysis
  • Palpitations

Hyperkalemia is suggested in any patient with a predisposition toward elevated potassium level. Potential potassium level elevation is observed in the following:

  • Acute or chronic renal failure, especially in patients who are on dialysis
  • Trauma, including crush injuries (rhabdomyolysis), or burns
  • Ingestion of foods high in potassium (eg, bananas, oranges, high-protein diets, tomatoes, salt substitutes). This alone is not likely to cause clinically significant hyperkalemia in most people; it is often a contributing factor to an acute potassium elevation.
  • Medications - Potassium supplements, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), beta-blockers, digoxin, succinylcholine, and digitalis glycoside
  • Medication combinations (ie, spironolactone, ACE inhibitors)[7]
  • Redistribution - Metabolic acidosis (diabetic ketoacidosis [DKA]), catabolic states
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Physical

Evaluation of vital signs is essential to determine hemodynamic stability and presence of cardiac arrhythmias related to the hyperkalemia.[1]

Cardiac examination may reveal extrasystoles, pauses, or bradycardia.

Neurologic examination may reveal diminished deep tendon reflexes or decreased motor strength.

In rare cases, muscular paralysis and hypoventilation may be observed.

Search for the stigmata of renal failure, such as edema, skin changes, and dialysis sites.

Look for signs of trauma that could put the patient at risk for rhabdomyolysis.

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Causes

Pseudohyperkalemia may result from the following:

  • Hemolysis (in laboratory tube) most common
  • Thrombocytosis
  • Leukocytosis
  • Venipuncture technique (ie, ischemic blood draw from prolonged tourniquet application)

Redistribution may result from the following:

  • Acidosis
  • Insulin deficiency
  • Beta-blocker drugs
  • Acute digoxin intoxication or overdose
  • Succinylcholine[8]
  • Arginine hydrochloride
  • Hyperkalemic familial periodic paralysis

Excessive endogenous potassium load may result from the following:

  • Hemolysis
  • Rhabdomyolysis
  • Internal hemorrhage

Excessive exogenous potassium load may result from the following:

  • Parenteral administration
  • Excess in diet
  • Potassium supplements
  • Salt substitutes

Diminished potassium excretion may result from the following:

  • Decreased glomerular filtration rate (eg, acute or end-stage chronic renal failure)
  • Decreased mineral corticoid activity
  • Defect in tubular secretion (eg, renal tubular acidosis II and IV)
  • Drugs (eg, NSAIDs, cyclosporine, potassium-sparing diuretics)

Laboratory error may be the cause of hyperkalemia.[9]

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Contributor Information and Disclosures
Author

David Garth, MD Attending Physician, Department of Emergency Medicine, Mary Washington Hospital

David Garth, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References
  1. Tran HA. Extreme hyperkalemia. South Med J. 2005 Jul. 98(7):729-32. [Medline].

  2. Khanna A, White WB. The management of hyperkalemia in patients with cardiovascular disease. Am J Med. 2009 Mar. 122(3):215-21. [Medline].

  3. Einhorn LM, Zhan M, Hsu VD, et al. The frequency of hyperkalemia and its significance in chronic kidney disease. Arch Intern Med. 2009 Jun 22. 169(12):1156-62. [Medline].

  4. Segura J, Ruilope LM. Hyperkalemia risk and treatment of heart failure. Heart Fail Clin. 2008 Oct. 4(4):455-64. [Medline].

  5. Weisberg LS. Management of severe hyperkalemia. Crit Care Med. 2008 Dec. 36(12):3246-51. [Medline].

  6. Krogager ML, Eggers-Kaas L, Aasbjerg K, et al. Short-term mortality risk of serum potassium levels in acute heart failure following myocardial infarction. Eur Heart J Cardiovasc Pharmacother. 2015 Oct. 1 (4):245-251. [Medline]. [Full Text].

  7. Schepkens H, Vanholder R, Billiouw JM, Lameire N. Life-threatening hyperkalemia during combined therapy with angiotensin-converting enzyme inhibitors and spironolactone: an analysis of 25 cases. Am J Med. 2001 Apr 15. 110(6):438-41. [Medline].

  8. Gronert GA, Theye RA. Pathophysiology of hyperkalemia induced by succinylcholine. Anesthesiology. 1975 Jul. 43(1):89-99. [Medline]. [Full Text].

  9. Hawkins RC. Poor knowledge and faulty thinking regarding hemolysis and potassium elevation. Clin Chem Lab Med. 2005. 43(2):216-20. [Medline].

  10. Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective?. J Am Soc Nephrol. 2010 May. 21(5):733-5. [Medline].

  11. Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective?. J Am Soc Nephrol. 2010 May. 21(5):733-5. [Medline].

  12. Rogers FB, Li SC. Acute colonic necrosis associated with sodium polystyrene sulfonate (Kayexalate) enemas in a critically ill patient: case report and review of the literature. J Trauma. 2001 Aug. 51(2):395-7. [Medline].

  13. McGowan CE, Saha S, Chu G, Resnick MB, Moss SF. Intestinal necrosis due to sodium polystyrene sulfonate (Kayexalate) in sorbitol. South Med J. 2009 May. 102(5):493-7. [Medline].

  14. Lee J, Moffett BS. Treatment of pediatric hyperkalemia with sodium polystyrene sulfonate. Pediatr Nephrol. 2016 May 23. [Medline].

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Widened QRS complexes in hyperkalemia.
Widened QRS complexes in a patient whose serum potassium level was 7.8 mEq/L.
ECG of a patient with pretreatment potassium level of 7.8 mEq/L and widened QRS complexes after receiving 1 ampule of calcium chloride. Notice narrowing of QRS complexes and reduction of T waves.
 
 
 
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