Hyperkalemia in Emergency Medicine Clinical Presentation

  • Author: David Garth, MD; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Apr 25, 2012
 

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)[5]
  • Redistribution - Metabolic acidosis (diabetic ketoacidosis [DKA]), catabolic states
Next

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.

Previous
Next

Causes

Pseudohyperkalemia

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

Redistribution

  • Acidosis
  • Insulin deficiency
  • Beta-blocker drugs
  • Acute digoxin intoxication or overdose
  • Succinylcholine[6]
  • Arginine hydrochloride
  • Hyperkalemic familial periodic paralysis

Excessive endogenous potassium load

  • Hemolysis
  • Rhabdomyolysis
  • Internal hemorrhage

Excessive exogenous potassium load

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

Diminished potassium excretion

  • 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 [7]

Previous
Proceed to Differential Diagnoses
 
 
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

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

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

I would like to thank my wife Mary, and my children, for allowing me the time away from them to keep on researching.

References

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

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

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

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

  5. 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. Apr 15 2001;110(6):438-41. [Medline].

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

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

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

  9. 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. May 2010;21(5):733-5. [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. May 2010;21(5):733-5. [Medline].

  11. 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. Aug 2001;51(2):395-7. [Medline].

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

  13. [Guideline] AHA/ILCOR Guidelines. American Heart Association in Collaboration with the International Liaison Committee on Resuscitation: Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: an international consensus on science. Circulation. 2000;102:I1-I384.

  14. Allon M, Dunlay R, Copkney C. Nebulized albuterol for acute hyperkalemia in patients on hemodialysis. Ann Intern Med. Mar 15 1989;110(6):426-9. [Medline].

  15. Charytan D, Goldfarb DS. Indications for hospitalization of patients with hyperkalemia. Arch Intern Med. Jun 12 2000;160(11):1605-11. [Medline].

  16. Commerford PJ, Lloyd EA. Arrhythmias in patients with drug toxicity, electrolyte, and endocrine disturbances. Med Clin North Am. Sep 1984;68(5):1051-78. [Medline].

  17. Davey M. Calcium for hyperkalaemia in digoxin toxicity. Emerg Med J. Mar 2002;19(2):183. [Medline].

  18. Gennari FJ. Disorders of potassium homeostasis. Hypokalemia and hyperkalemia. Crit Care Clin. Apr 2002;18(2):273-88, vi. [Medline].

  19. Kao KC, Huang CC, Tsai YH, Lin MC, Tsao TC. Hyperkalemic cardiac arrest successfully reversed by hemodialysis during cardiopulmonary resuscitation: case report. Chang Gung Med J. Sep 2000;23(9):555-9. [Medline].

  20. Mandal AK. Hypokalemia and hyperkalemia. Med Clin North Am. May 1997;81(3):611-39. [Medline].

  21. Martinez-Vea A, Bardají A, Garcia C, Oliver JA. Severe hyperkalemia with minimal electrocardiographic manifestations: a report of seven cases. J Electrocardiol. Jan 1999;32(1):45-9. [Medline].

  22. Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. Oct 2000;18(6):721-9. [Medline].

  23. Mitch WE, Wilcox CS. Disorders of body fluids, sodium and potassium in chronic renal failure. Am J Med. Mar 1982;72(3):536-50. [Medline].

  24. Moore ML, Bailey RR. Hyperkalaemia in patients in hospital. N Z Med J. Oct 25 1989;102(878):557-8. [Medline].

  25. Nijsten MW, de Smet BJ, Dofferhoff AS. Pseudohyperkalemia and platelet counts. N Engl J Med. Oct 10 1991;325(15):1107. [Medline].

  26. Oster JR, Perez GO, Vaamonde CA. Relationship between blood pH and potassium and phosphorus during acute metabolic acidosis. Am J Physiol. Oct 1978;235(4):F345-51. [Medline].

  27. Perazella MA. Drug-induced hyperkalemia: old culprits and new offenders. Am J Med. Sep 2000;109(4):307-14. [Medline].

  28. Pruitt BA Jr, Goodwin CW Jr, Vaughan GM, et al. The metabolic problems of the burn patient. Acta Chir Scand Suppl. 1985;522:119-39. [Medline].

  29. Ranjit S, Kissoon N, Jayakumar I. Aggressive management of dengue shock syndrome may decrease mortality rate: a suggested protocol. Pediatr Crit Care Med. Jul 2005;6(4):412-9. [Medline].

  30. Sacchetti A, Stuccio N, Panebianco P, Torres M. ED hemodialysis for treatment of renal failure emergencies. Am J Emerg Med. May 1999;17(3):305-7. [Medline].

  31. Williams ME. Endocrine crises. Hyperkalemia. Crit Care Clin. Jan 1991;7(1):155-74. [Medline].

  32. Wong SL, Maltz HC. Albuterol for the treatment of hyperkalemia. Ann Pharmacother. Jan 1999;33(1):103-6. [Medline].

  33. Zull DN. Disorders of potassium metabolism. Emerg Med Clin North Am. Nov 1989;7(4):771-94. [Medline].

 
Previous
Next
 
Peaked T waves in hyperkalemia.
Peaked T waves in hyperkalemia.
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.