12-phase flow (12)

1. 1FRAME
   Severity by K (severe ≥6.5, moderate 5.5-6.4, mild 5.0-5.4) + ECG severity (peaked T ~6.5 → wide QRS ~7 → sine wave ~8 → asystole >9); STAT calcium for ANY ECG change regardless of K number (NICE 2020 verify; KDOQI 2020 verify)
   inputs: serum_potassium_value, ecg_12_lead
   advance: severity + ECG severity stratified
2. 2ENTRY
   Neuromuscular sx (weakness, paresthesias, paralysis, palpitations); cardiac sx (peri-arrest, arrhythmia); volume status; pseudohyperK exclusion (tight tourniquet, hemolyzed, leukocytosis, thrombocytosis)
   inputs: neuromuscular_symptoms
   advance: symptom severity captured + pseudo excluded
3. 3CONTEXT
   Age + sex + vitals (BP, HR); medication review (ACEI/ARB/MRA/NSAID/trimethoprim/beta-blocker/heparin/tacrolimus/cyclosporine/salt-substitute); CKD/AKI/eGFR; recent chemo (TLS); rhabdomyolysis trigger; adrenal steroid history; massive transfusion; succinylcholine anesthesia; dietary/salt-substitute
   inputs: age, sex, sbp, hr, medications_acei_arb_mra_nsaid_trimethoprim_beta_blocker, ckd_aki_status_eGFR, recent_chemo_or_malignancy, rhabdomyolysis_trigger_crush_exertional_statin_cocaine, adrenal_steroid_history, massive_transfusion_status, recent_succinylcholine_anesthesia, dietary_or_salt_substitute_intake
   advance: context complete
4. 4RED_FLAGS
   K ≥6.5 with ECG changes (peaked T, wide QRS, sine wave) → STAT calcium gluconate; cardiac arrest / peri-arrest → ACLS + calcium chloride; severe acidosis (pH <7.2) → bicarbonate consideration; oliguric/anuric AKI → dialysis prep
   inputs: serum_potassium_value, ecg_12_lead, venous_blood_gas_or_abg
   advance: no immediate cardiac compromise OR calcium-stabilization + ICU activated
5. 5INITIAL_WORKUP
   BMP + anion gap (NAGMA type 4 RTA vs AGMA DKA/lactic); CBC (pseudo screen); venous blood gas or ABG (acidosis severity); CK + myoglobin (rhabdo); UA/PO4/Ca/LDH (TLS); plasma K if pseudo suspected; lactate (sepsis/ischemia)
   inputs: bmp_full_with_anion_gap, cbc_with_diff, venous_blood_gas_or_abg, creatine_kinase_myoglobin, uric_acid_phosphate_calcium_ldh, plasma_potassium_repeat_if_pseudoK_suspected, lactate_for_ischemia_or_sepsis
   actions: panel.cbc, panel.renal, panel.lft
   advance: pseudo excluded + cause stratification possible
6. 6BRANCHING_WORKUP
   CKD/AKI → renal engine route. Recent chemo → TLS workup + route heme.tumor-lysis-syndrome.core.v1. Rhabdo → CK trend + IVF + alkalinize + compartment watch. ACEI/ARB/MRA → withdraw/substitute + binder. Adrenal → cortisol + ACTH stim + empiric hydrocortisone + route endo.adrenal-crisis.core.v1. Type 4 RTA → aldo/renin + fludrocortisone. Pseudo confirmed → no treatment, repeat with proper technique.
   inputs: cortisol_acth_stim_if_adrenal_suspected, aldosterone_renin_if_type_4_rta_suspected
   advance: definitive cause identified or routed
7. 7DIFFERENTIAL
   Decreased excretion: CKD, AKI, RAAS inhibitor, adrenal insufficiency, type 4 RTA, K-sparing diuretic, NSAID, trimethoprim, heparin. Increased intake: dietary, salt-substitute, IV/PO K supplements. Cell shift out: acidosis (DKA, lactic, uremic), rhabdomyolysis, TLS, hemolysis, succinylcholine, beta-blocker, digoxin toxicity. Pseudo: tight tourniquet, hemolyzed sample, thrombocytosis, leukocytosis. Transfusion-related: massive PRBC.
   advance: cause ranked
8. 8RISK_STRATIFICATION
   Severity by K + ECG (most important); acidosis severity (drives K shift); renal function (drives dialysis decision); concurrent comorbidities (CHF, cirrhosis, CKD); medication burden (RAAS-inhibitor preservation strategy)
   advance: risk stratification documented
9. 9TREATMENT
   STAT IV calcium for K ≥6.5 with ECG changes — calcium gluconate 10% 10 mL (1 g) IV over 2-3 min via peripheral OR calcium chloride 10% 5 mL via central. K-shift: insulin 10 U regular IV + D50 25 g (caution glucose); albuterol 10-20 mg neb (additive). Acidosis correction: NaHCO3 50-150 mEq IV if pH <7.2. K removal: furosemide 40-80 mg IV (if not anuric); patiromer 8.4 g PO OR sodium zirconium cyclosilicate 10 g PO TID (slower onset); EMERGENCY HEMODIALYSIS for refractory / anuric / severe / failing medical. AVOID sodium polystyrene sulfonate (Kayexalate) chronic use (colonic necrosis risk — FDA boxed warning). Adrenal → hydrocortisone empiric. TLS → rasburicase + IVF + route heme. Discontinue offending meds (ACEI/ARB/MRA/NSAID/trimethoprim/salt-substitute) or dose-adjust with binder support.
   inputs: serum_potassium_value, ecg_12_lead
   advance: cardiac stabilized + K removal active
10. 10DISPOSITION
    Discharge: confirmed pseudohyperK; chronic mild K 5.0-5.4 on outpatient binder + dietary counseling. Observation: moderate K 5.5-6.0 responding to medical mgmt. Ward: K 6.0-6.5 without ECG OR moderate with cause identified. Telemetry: K ≥6.5 OR ECG changes OR pending dialysis. ICU: severe symptomatic, ECG changes, acidosis with K shift, dialysis-dependent. Routes: syndrome.hyperkalemia.core.v1 (definitive); renal.aki.v1; neph.ckd.core.v1; heme.tumor-lysis-syndrome.core.v1; endo.adrenal-crisis.core.v1.
    advance: disposition assigned + downstream handoff complete
11. 11MONITORING
    Continuous cardiac monitor + serial ECG q15 min during peak treatment; K q1-2h until <5.5; BMP + glucose q1h during insulin/D50 (hypoglycemia risk lasts >1 h after dose); Ca + Mg + PO4 trend; pH trend; UOP q1h; CK trend if rhabdo; albuterol + insulin response
    inputs: serum_potassium_value, ecg_12_lead
    advance: K controlled + ECG normalized + cause addressed
12. 12FOLLOWUP
    Nephrology for CKD / AKI / chronic binder; deprescribing offending meds (or substituting + binder for RAAS preservation); endocrinology for adrenal / type 4 RTA; oncology / heme for TLS prevention; dietary K counseling; recurrence prevention; K-binder education (patiromer, ZS-9)
    advance: long-term plan in place + follow-up scheduled