Hyperkalemia

≈ 154.3 lb
Pediatric
Alert sounds
ECG findings — pick worst
5 steps triggered
Earliest finding. ECG progression: peaked T → PR long → loss P → wide QRS → sine wave.
Stabilize
Indicated
Calcium gluconate 10%
1–2 g (10–20 mL) IV over 5–10 min
Onset: 1–3 min
Duration: 30–60 min
Use if K > 6 or any EKG change. May repeat in 5 min if EKG persists.
Calcium chloride 10% (central line)
0.5–1 g (5–10 mL) IV slow
Onset: 1–3 min
Duration: 30–60 min
3× more elemental Ca than gluconate; vesicant — central preferred.
Shift
Indicated
Regular insulin + dextrose
10 u IV + 25 g D50 (50 mL) — use 5 u if glu < 250 or AKI
Onset: 10–20 min
Duration: 4–6 h
Recheck glucose at 30, 60 min — risk of hypoglycemia.
Indicated
Albuterol nebulized
10–20 mg neb (4–8 × standard 2.5 mg dose)
Onset: 15–30 min
Duration: 2–4 h
Synergistic with insulin. ↓ K by 0.5–1 mEq/L. Caution tachyarrhythmias.
Sodium bicarbonate
50–100 mEq IV (1–2 amps) over 5–10 min
Onset: 30+ min
Duration: variable
Most useful in metabolic acidosis. Limited effect in isolated hyperK.
Eliminate
Indicated
Sodium zirconium cyclosilicate (Lokelma)
10 g PO × 1 (then 10 g TID × 48 h)
Onset: 1 h
Duration: ongoing
Onset faster than kayexalate. Preferred GI binder.
Patiromer (Veltassa)
8.4 g PO daily
Onset: 7 h
Duration: ongoing
Slower onset — chronic management.
Sodium polystyrene (Kayexalate)
15–30 g PO with sorbitol
Onset: 2–6 h
Duration: 4–6 h
⚠ Risk of intestinal necrosis — avoid postop, ileus, neonates.
Indicated
Furosemide
40–80 mg IV
Onset: 15 min
Duration: 2–6 h
Requires intact renal function & adequate volume.
Hemodialysis
Definitive — call nephrology
Onset: immediate (during HD)
Duration: until corrected
ESRD, refractory K, severe AKI, symptomatic.
Causes to address
  • AKI / CKD · missed dialysis
  • K-sparing meds: ACEi/ARB, spironolactone, K supplements, NSAIDs, TMP-SMX
  • Rhabdo · TLS · hemolysis · burns
  • Adrenal insufficiency · DKA
  • Pseudohyperkalemia (hemolyzed sample) — recheck if asymptomatic & EKG normal

Educational aid only — verify against local hyperkalemia protocol.