Metabolic, toxicology and environment
Hyperkalemia Algorithm
Stabilize the heart, shift potassium in, remove it
1 Confirm and look at the ECG
- Repeat the level if hemolysis is possible, but do not wait to treat ECG changes
- Stop potassium sources: infusions, supplements, ACE inhibitors, ARBs, spironolactone, trimethoprim
ECG changes or K 6.5 or more → step 2K 6.0–6.4, no ECG changes → step 3K 5.5–5.9, no ECG changes → step 4
2 Stabilize the membrane: calcium
- Calcium gluconate 10% 30 mL (3 g) IV over 5–10 min, or calcium chloride 10% 10 mL through a central line
- Continuous cardiac monitoring
- Repeat if ECG changes persist after 5–10 min
3 Shift potassium into cells
- Regular insulin 10 units IV with 25 g dextrose (50 mL D50), or 5 units in kidney failure to limit hypoglycemia
- Glucose every hour for 4–6 hours; add dextrose 10% infusion if glucose is under 250
- Albuterol 10–20 mg nebulized (adds about 0.5–1 mEq/L)
- Sodium bicarbonate only with metabolic acidosis
4 Remove potassium from the body
- Loop diuretic if the patient makes urine
- Sodium zirconium cyclosilicate 10 g three times daily, or patiromer
- Dialysis for refractory hyperkalemia, kidney failure or a large ongoing load (rhabdomyolysis, tumor lysis)
- Recheck potassium 1–2 hours after treatment and again at 4–6 hours
5 Urgent dialysis
- Call nephrology for hemodialysis (removes potassium fastest)
- Keep shifting therapy going until dialysis starts
- Watch for rebound potassium after insulin wears off
Drugs in this algorithm
Related one-pagers
- ACLS Algorithms in BriefBradycardia with a pulse: Usually under 50/min. Treat if it causes hypotension, acute confusion, shock, ischemic chest pain or acute heart failure; look for ischemia, drugs, hypoxia, hyperkalemia.
- Rhythm GalleryST and T changes: Hyperkalemia: peaked T, flat P, widening QRS, then a sine wave. With ECG changes, IV calcium first; then shift K (insulin with glucose, albuterol), then remove it.
- BurnsInhalation injury, airway, CO and cyanide: Succinylcholine is acceptable in the first 24 hours (Datta 2022); after that, upregulated acetylcholine receptors risk severe hyperkalemia until the wounds heal.
- Toxidromes and AntidotesCardiotoxic drugs: TCAs, β-blockers, CCBs, digoxin, LAST: Digoxin inhibits Na⁺/K⁺-ATPase: hyperkalemia in acute poisoning and increased automaticity with AV block (PVCs, atrial tachycardia with block, bidirectional VT); chronic toxicity adds confusion and yellow-green vision. Before Fab, potassium above 5.5 in acute poisoning predicted death (Bismuth 1973). Fab resolves dysrhythmias in 50–90%, usu
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