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Hyperkalemia in Emergency Medicine Medication

  • Author: David Garth, MD; Chief Editor: Erik D Schraga, MD  more...
Updated: Dec 16, 2015

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. The onset of action is less than 5 min and lasts about 30-60 minutes. Doses should be titrated with constant monitoring of ECG changes during administration; repeat the dose if ECG changes do not normalize within 3-5 minutes.



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 minutes of administration.

Insulin (Humulin, Humalog, Novolin)


Insulin stimulates cellular uptake of K+ within 20-30 minutes; 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 ions neutralize hydrogen ions and raise urinary and blood pH. The onset of action is within minutes and lasts approximately 15-30 minutes. It is only likely to be efficacious if underlying acidosis is present. Monitor blood pH to avoid excess alkalosis.

Use 8.4% solution in adults and children and 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)


Albuterol is an adrenergic agonist that increases the plasma insulin concentration, which may, in turn, help shift K+ into the intracellular space. It lowers K+ levels by 0.5-1.5 mEq/L. Albuterol can be very beneficial in patients with renal failure when fluid overload is a concern. The onset of action is 30 minutes; the duration of action is 2-3 hours.



Class Summary

These agents cause the loss of potassium through the kidney.

Furosemide (Lasix)


Effects are slow and frequently take an hour to begin. Furosemide lowers the potassium level by an inconsistent amount. Large doses may be needed in renal failure.

Ethacrynic acid (Edecrin)


Ethacrynic acid increases the excretion of water by interfering with the chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the 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)


Sodium polystyrene sulfonate exchanges Na+ for K+ and binds it in the gut, primarily in the large intestine, decreasing total body potassium. The onset of action after oral administration ranges from 2-12 hours (longer when administered rectally). It lowers K+ over 1-2 hours, with a duration of action of 4-6 hours. The potassium level drops by approximately 0.5-1 mEq/L. Multiple doses are usually necessary.



Class Summary

These agents have been successfully used in the treatment of acute SLOW released oral potassium overdose.

Magnesium sulfate


Magnesium sulfate is a nutritional supplement in hyperalimentation; it is a 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 an optimum metabolic response. Give intravenously for acute suppression of torsade. Repeat doses are dependent upon continuing the presence of a patellar reflex and adequate respiratory function.

Contributor Information and Disclosures

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.

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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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