Hyperkalemia in Emergency Medicine Medication
- Author: David Garth, MD; Chief Editor: Erik D Schraga, MD more...
Medication Summary
Direct treatment is aimed at stabilizing the myocardium, shifting potassium from the extracellular environment to the intracellular compartment, and promoting the renal excretion and GI loss of potassium.
Electrolyte supplements
Class Summary
These agents are used to treat hyperkalemia and to reduce the risk of ventricular fibrillation caused by hyperkalemia. They act quickly and can be lifesaving, thus they are the first-line treatment for severe hyperkalemia when the ECG shows significant abnormalities (eg, widening of QRS interval, loss of P wave, cardiac arrhythmias). Calcium usually is not indicated when the ECG shows only peaked T waves.
Calcium chloride (Kalcinate)
Calcium increases threshold potential, thus restoring normal gradient between threshold potential and resting membrane potential, which is elevated abnormally in hyperkalemia. One ampule of calcium chloride has approximately 3 times more calcium than calcium gluconate. Onset of action is < 5 min and lasts about 30-60 min. Doses should be titrated with constant monitoring of ECG changes during administration; repeat dose if ECG changes do not normalize within 3-5 min.
Antidotes
Class Summary
Insulin is administered with glucose to facilitate the uptake of glucose into the cell, bringing potassium with it.
Dextrose (D-Glucose)
Glucose and insulin temporarily shift K+ into cells; effects occur within first 30 min of administration.
Insulin (Humulin, Humalog, Novolin)
Stimulates cellular uptake of K+ within 20-30 min; administer glucose along with insulin to prevent hypoglycemia (monitor blood glucose levels closely).
Alkalinizing agents
Class Summary
These agents increase the pH, which results in a temporary potassium shift from the extracellular to the intracellular environment. These agents enhance the effectiveness of insulin in patients with acidemia.
Sodium bicarbonate (Neut)
Bicarbonate ion neutralizes hydrogen ions and raises urinary and blood pH. Onset of action within minutes, lasts approximately 15-30 min. Only likely to be efficacious if underlying acidosis present. Monitor blood pH to avoid excess alkalosis.
Use 8.4% solution in adults and children, 4.2% solution in infants.
Beta2-adrenergic agonists
Class Summary
These agents promote cellular reuptake of potassium, possibly via the cyclic gAMP receptor cascade.
Albuterol (Ventolin, Proventil)
Adrenergic agonist that increases plasma insulin concentration, which may in turn help shift K+ into intracellular space. Lowers K+ level by 0.5-1.5 mEq/L. Can be very beneficial in patients with renal failure when fluid overload is concern. Onset of action is 30 min; duration of action is 2-3 h.
Diuretics
Class Summary
These agents cause the loss of potassium through the kidney.
Furosemide (Lasix)
Effects are slow and frequently take an hour to begin. Lowers potassium level by inconsistent amount. Large doses may be needed in renal failure.
Ethacrynic acid (Edecrin)
Increases excretion of water by interfering with chloride-binding cotransport system, which in turn inhibits sodium and chloride reabsorption in ascending loop of Henle and distal renal tubule.
Binding resins
Class Summary
These agents promote exchange of potassium for sodium in GI system.
Sodium polystyrene sulfonate (Kayexalate)
Exchanges Na+ for K+ and binds it in gut, primarily in large intestine, decreasing total body potassium. Onset of action after PO ranges from 2-12 h (longer when administered rectally). Lowers K+ over 1-2 h with duration of action of 4-6 h. Potassium level drops by approximately 0.5-1 mEq/L.
Multiple doses usually necessary.
Electrolytes
Class Summary
These agents have been successfully used in the treatment of acute SLOW released oral potassium overdose.
Magnesium sulfate
Nutritional supplement in hyperalimentation; cofactor in enzyme systems involved in neurochemical transmission and muscular excitability. In adults, 60-180 mEq of potassium, 10-30 mEq of magnesium, and 10-40 mmol of phosphate per day may be necessary for optimum metabolic response. Give IV for acute suppression of torsade. Repeat doses are dependent upon continuing presence of patellar reflex and adequate respiratory function.
Tran HA. Extreme hyperkalemia. South Med J. Jul 2005;98(7):729-32. [Medline].
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].
Segura J, Ruilope LM. Hyperkalemia risk and treatment of heart failure. Heart Fail Clin. Oct 2008;4(4):455-64. [Medline].
Weisberg LS. Management of severe hyperkalemia. Crit Care Med. Dec 2008;36(12):3246-51. [Medline].
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].
Gronert GA, Theye RA. Pathophysiology of hyperkalemia induced by succinylcholine. Anesthesiology. Jul 1975;43(1):89-99. [Medline]. [Full Text].
Hawkins RC. Poor knowledge and faulty thinking regarding hemolysis and potassium elevation. Clin Chem Lab Med. 2005;43(2):216-20. [Medline].
Khanna A, White WB. The management of hyperkalemia in patients with cardiovascular disease. Am J Med. Mar 2009;122(3):215-21. [Medline].
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].
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].
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].
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].
[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.
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].
Charytan D, Goldfarb DS. Indications for hospitalization of patients with hyperkalemia. Arch Intern Med. Jun 12 2000;160(11):1605-11. [Medline].
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].
Davey M. Calcium for hyperkalaemia in digoxin toxicity. Emerg Med J. Mar 2002;19(2):183. [Medline].
Gennari FJ. Disorders of potassium homeostasis. Hypokalemia and hyperkalemia. Crit Care Clin. Apr 2002;18(2):273-88, vi. [Medline].
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].
Mandal AK. Hypokalemia and hyperkalemia. Med Clin North Am. May 1997;81(3):611-39. [Medline].
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].
Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. Oct 2000;18(6):721-9. [Medline].
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].
Moore ML, Bailey RR. Hyperkalaemia in patients in hospital. N Z Med J. Oct 25 1989;102(878):557-8. [Medline].
Nijsten MW, de Smet BJ, Dofferhoff AS. Pseudohyperkalemia and platelet counts. N Engl J Med. Oct 10 1991;325(15):1107. [Medline].
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].
Perazella MA. Drug-induced hyperkalemia: old culprits and new offenders. Am J Med. Sep 2000;109(4):307-14. [Medline].
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].
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].
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].
Williams ME. Endocrine crises. Hyperkalemia. Crit Care Clin. Jan 1991;7(1):155-74. [Medline].
Wong SL, Maltz HC. Albuterol for the treatment of hyperkalemia. Ann Pharmacother. Jan 1999;33(1):103-6. [Medline].
Zull DN. Disorders of potassium metabolism. Emerg Med Clin North Am. Nov 1989;7(4):771-94. [Medline].
Print
