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symptom.hyperkalemia-workup.v1

Hyperkalemia symptom-triage (ED workup + cross-engine to syndrome)

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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)

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severity + ECG severity stratified

Patient inputs (24)

Age shifts priors: elderly → CKD + medication (ACEI/ARB/MRA, NSAIDs); young adult → rhabdomyolysis (exertional, MDMA), TLS, succinylcholine; AKI + chronic mineralocorticoid def (verify NICE 2020)

Sex-based — uncommon distinction; pregnancy → physiologic K considerations; both sexes equal risk for medication-induced

ACEI/ARB/MRA (spironolactone, eplerenone), NSAIDs, trimethoprim (functional K-sparing), beta-blocker (impaired uptake), heparin (mineralocorticoid suppression), tacrolimus, cyclosporine, salt-substitute — drug-induced; deprescribe or substitute

CKD (eGFR <45 chronic risk; <30 acute risk; ESRD anuric) + AKI (oliguric / anuric) → impaired K excretion; route neph.ckd.core.v1 / renal.aki.v1

Chronic steroid + recent taper / sudden withdrawal OR Addison features (hyperpigmentation, hyponatremia, hypotension) → adrenal crisis; STAT hydrocortisone empiric; route endo.adrenal-crisis.core.v1

Hypotension + hyperK + hypoNa → adrenal crisis suspicion; STAT hydrocortisone empiric

Bradycardia + hyperK → cardiac compromise; tachycardia + hyperK → compensatory or sepsis overlap

Weakness, paresthesias, paralysis, palpitations, cardiac arrest — neuromuscular + cardiac sx escalate urgency; flaccid paralysis advanced; cardiac arrest = peri-arrest

Severity by K: severe ≥6.5, moderate 5.5-6.4, mild 5.0-5.4 — drives calcium-stabilization indication + monitoring intensity

ECG severity: peaked T (~6.5) → PR prolongation → P loss + wide QRS (~7) → sine wave (~8) → asystole (>9); STAT calcium for ANY ECG change regardless of K level; ECG severity is more important than K number

BMP: Na (low → adrenal), K (confirm), Cl, HCO3 (NAGMA in type 4 RTA; AGMA in DKA/lactic/uremic), BUN/Cr (renal), glucose (DKA), Ca (low in TLS, hypocalcemia worsens cardiotoxicity), Mg (low Mg → refractory hypoK; high Mg → repletion error), PO4 (high in TLS, AKI)

Leukocytosis / thrombocytosis → pseudohyperkalemia from in vitro lysis; CBC also screens for TLS (recent chemo)

Acidosis worsens hyperK (shifts K out of cell); pH <7.2 → bicarbonate consideration; severe acidosis → dialysis prep

AM cortisol + ACTH stim (cosyntropin) → adrenal insufficiency; empiric hydrocortisone first if clinical suspicion

Aldosterone + plasma renin activity → hyporeninemic hypoaldosteronism (type 4 RTA); fludrocortisone may help

Recent chemo (24-72 h) for high-burden malignancy (lymphoma, AML, ALL) → TLS; lab workup (uric acid, phosphate, calcium, LDH) → route heme.tumor-lysis-syndrome.core.v1

Crush injury / prolonged immobility / exertional event / statin / fibrate / cocaine / heat stroke / seizure → rhabdomyolysis; CK + UA myoglobin; aggressive IVF; compartment syndrome watch

Massive transfusion (>10 units PRBC, especially aged / not washed) → K release; trauma resuscitation context; use washed / fresh PRBC + monitor K

Succinylcholine in burn / crush / spinal cord / chronic immobility / muscular dystrophy → depolarization-induced K rise (life-threatening); AVOID succinylcholine in these populations (use rocuronium)

Excessive K intake (bananas, oranges, salt-substitute KCl, supplements) in setting of impaired excretion → diet-induced; counsel restriction

CK >5000 + myoglobinuria → rhabdomyolysis; CK trend; UA myoglobin

TLS lab definition: 25% rise in UA/K/PO4 or 25% drop in Ca; LDH high; recent chemo for high-burden malignancy

If hemolyzed sample / tight tourniquet / leukocytosis / thrombocytosis → repeat with plasma (lithium-heparin) tube and gentle draw before treating

Lactate elevated → ischemic / septic / shock → AGMA contributing to K shift

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Severity triggers (8)

8 need judgement
  • informationallife_threateningsevere_K_ge_6_5_with_ecg_changes
    K ≥6.5 with ECG changes (peaked T → wide QRS → sine wave → asystole) — STAT calcium gluconate 1 g IV (10 mL of 10%) over 2-3 min for membrane stabilization + insulin 10 U IV + D50 25 g + albuterol 10-20 mg neb + sodium bicarbonate if pH <7.2 + binder + dialysis prep (NICE 2020 verify; KDOQI 2020 verify)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcardiac_arrest_peri_arrest_hyperkalemia
    Cardiac arrest OR peri-arrest with confirmed hyperkalemia — ACLS + calcium chloride 1 g IV via central + insulin/D50 + bicarbonate + IMMEDIATE hemodialysis arrangement
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningadrenal_crisis_hyperkalemia
    Hyperkalemia + hyponatremia + hypotension + steroid history OR hyperpigmentation / Addison features — adrenal crisis; STAT hydrocortisone 100 mg IV (empiric) + fluids → route endo.adrenal-crisis.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_kidney_injury_with_hyperkalemia
    AKI (acute Cr rise + oliguria/anuria) + hyperkalemia → route renal.aki.v1; cause-directed IVF if pre-renal, dialysis if anuric / refractory medical mgmt
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretumor_lysis_syndrome_hyperkalemia
    Recent chemotherapy (24-72 h) for high-burden malignancy (lymphoma, AML, ALL) + hyperK + hyperuricemia + hyperphosphatemia + hypocalcemia + LDH high — tumor lysis; rasburicase 0.2 mg/kg IV (check G6PD first) + IVF + binder; route heme.tumor-lysis-syndrome.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdomyolysis_with_hyperkalemia
    Crush injury / exertional / statin / cocaine / heat stroke / seizure + hyperK + CK >5000 + myoglobinuria — rhabdomyolysis; aggressive NS 200-500 mL/h titrate UOP 200-300 mL/h + alkalinize urine pH >6.5 + monitor compartment syndrome
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechronic_CKD_with_RAAS_inhibitor_hyperkalemia
    CKD (eGFR <45) + ACEI/ARB/MRA (spironolactone, eplerenone) + hyperkalemia — withdraw or dose-adjust; alternative: patiromer or sodium zirconium cyclosilicate to preserve cardio-renal benefits (AMETHYST-DN PMID 25469712 verify; AMBER PMID 27093918 verify; HARMONIZE PMID 31959449 verify)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpseudohyperkalemia_confirmation
    Isolated K elevation without ECG changes + recent tight tourniquet / hemolyzed sample / thrombocytosis (platelets >500K) / leukocytosis (WBC >50K) — ALWAYS confirm pseudohyperK with repeat plasma K (lithium-heparin tube) gently drawn WITHOUT tourniquet before treating
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute hyperkalemia: membrane stabilization → intracellular shift → elimination (Turk J Emerg Med 2023; ED management)
axis: acute_hyperkalemia_ladderstep 1 - Membrane stabilization (any ECG change, or K >=6.5)
Selected step "Membrane stabilization (any ECG change, or K >=6.5)" — ECG changes of hyperkalemia (peaked T, wide QRS, sine wave) OR K >=6.5 mEq/L
  • calcium gluconate 10% 10 mL (1 g) IV over 2-3 min (repeat in 5 min if ECG unchanged); calcium chloride 10% via central line if peri-arrest
    first line
    cardiac membrane stabilizer
    triggers: ecg_changes, k_ge_6_5
    Does NOT lower K; antagonizes membrane excitability within minutes to prevent dysrhythmia while shift/elimination act (Turk J Emerg Med 2023)

ed playbook — drug actions (12)

  1. 1. calcium gluconate 10% (membrane stabilization)
    1 g IV (10 mL of 10% solution) over 2-3 min; may repeat × 1 if ECG persists; calcium chloride 10% 5 mL via central line (3× more elemental Ca) • IV • STAT, may repeat
    trigger: K ≥6.5 with ECG changes (peaked T, wide QRS, sine wave) OR K ≥7 regardless of ECG OR cardiac arrest / peri-arrest
    Membrane stabilization — does NOT lower K but prevents arrhythmia; onset 1-3 min, duration 30-60 min; bridge while K-shift drugs work; NICE 2020 verify; KDOQI 2020 verify
  2. 2. insulin (regular) + D50 (K-shift intracellular)
    Regular insulin 10 U IV bolus + D50 (25 g) IV bolus simultaneously; or D10W 250 mL infusion to avoid hypoglycemia • IV • STAT
    trigger: K ≥6.0 with ECG changes OR K ≥6.5 regardless
    Drives K into cells via Na/K-ATPase activation; onset 15-30 min, duration 4-6 h; hypoglycemia risk EXTENDS >1 h post-dose — monitor glucose q1h (Cochrane PMID 26577050 verify); reduce insulin to 5 U if glucose <250
  3. 3. albuterol (nebulized) — additive K-shift
    10-20 mg nebulized over 15 min (4-8x the asthma dose) • inhaled • STAT
    trigger: Adjunct to calcium + insulin/D50 for K ≥6.0
    Beta-2 agonist → cAMP → K shift intracellular; additive 0.5-1 mEq/L drop; onset 30 min; some patients non-responders; caution tachyarrhythmia and CAD
  4. 4. sodium bicarbonate (acidosis correction)
    50-150 mEq IV bolus over 15-30 min (50 mEq = 1 amp 8.4%); titrate to pH • IV • PRN
    trigger: pH <7.2 with hyperkalemia; severe metabolic acidosis
    Reverses acidosis-driven K shift OUT of cells; reduces ~0.5 mEq/L; caution Na load in volume-overload + CHF + cirrhosis; avoid mixing with calcium (precipitation)
  5. 5. furosemide IV (renal K excretion)
    40-80 mg IV (or higher in CKD up to 200-400 mg); titrate UOP • IV • PRN
    trigger: Adequate renal function (UOP) + K removal needed
    Loop diuretic increases distal K secretion; useful when UOP is preserved; AVOID in anuria or severe AKI; double dose in CKD due to tubular acid load
  6. 6. patiromer (chronic K binder)
    8.4 g PO daily; titrate up to 25.2 g PO daily • PO • daily
    trigger: Chronic hyperkalemia management OR RAAS inhibitor preservation (CKD with ACEI/ARB/MRA); also acute moderate K with slower onset acceptable (AMETHYST-DN PMID 25469712, verify)
    GI K binder (Ca-polymer); onset hours; preserves cardio-renal benefit of ACEI/ARB/MRA; AE: hypomagnesemia, constipation; takes 6 h apart from other PO meds
  7. 7. sodium zirconium cyclosilicate (Lokelma — ZS-9)
    10 g PO TID × 48 h (acute) then 5-15 g daily maintenance • PO • TID acute / daily maintenance
    trigger: Acute moderate K + maintenance therapy + RAAS inhibitor preservation (HARMONIZE PMID 31959449 verify; AMBER PMID 27093918 verify)
    Selective K binder, faster onset than patiromer (~1 h); FDA approved 2018; less constipation than patiromer; Na load consideration in CHF / HTN
  8. 8. hemodialysis (definitive K removal)
    Emergent hemodialysis 3-4 h session; ultrafiltration if volume overload • extracorporeal • emergent / repeat
    trigger: Refractory K + ECG changes despite medical mgmt OR anuria / ESRD OR severe acidosis / volume overload / pulmonary edema
    Removes 25-50 mEq K per session; useful in ESRD, anuric AKI, drug-refractory; access (tunneled catheter or AVF); arrange early — do not delay medical mgmt waiting for dialysis
  9. 9. hydrocortisone (adrenal crisis empiric)
    100 mg IV bolus then 50 mg IV q6h × 24-48 h • IV • q6h
    trigger: Adrenal crisis suspicion (hyperK + hypoNa + hypotension + steroid history OR hyperpigmentation)
    Empiric — do not wait for cortisol; route endo.adrenal-crisis.core.v1; mineralocorticoid effect at high dose helps K
  10. 10. rasburicase (TLS prevention/treatment)
    0.2 mg/kg IV × 1 dose (max 6 mg in adults); check G6PD first (hemolysis CI in G6PD deficient) • IV • single dose
    trigger: Tumor lysis syndrome (recent chemo + hyperK + hyperuricemia + hyperphosphatemia + hypocalcemia)
    Converts uric acid to allantoin (renal-excretable); CI in G6PD deficiency (hemolysis) + pregnancy; route heme.tumor-lysis-syndrome.core.v1
  11. 11. normal saline (rhabdomyolysis aggressive IVF)
    NS 200-500 mL/h titrate to UOP 200-300 mL/h; total 6-12 L in first 24 h • IV • continuous
    trigger: Rhabdomyolysis (CK >5000 + myoglobinuria)
    Aggressive forced diuresis to prevent AKI from myoglobin; alkalinize urine pH >6.5 with sodium bicarbonate (controversial); monitor compartment syndrome
  12. 12. discontinue offending medications
    N/A • medication management • one-time + ongoing
    trigger: Drug-induced (ACEI/ARB/MRA/NSAID/trimethoprim/beta-blocker/heparin/tacrolimus/cyclosporine/salt-substitute)
    Critical step; substitute non-offending alternative; or continue with binder (patiromer/ZS-9) if HF/CKD benefit > K risk per RELIEF/AMETHYST/AMBER trials

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: K ≥6.5 with ECG changes (peaked T → wide QRS → sine wave → asystole) — STAT calcium gluconate 1 g IV (10 mL of 10%) over 2-3 min → membrane stabilization + insulin 10 U IV + D50 25 g + albuterol 10-20 mg neb + sodium bicarbonate if acidotic + binder + dialysis prep (NICE 2020 verify; KDOQI 2020 verify); K 5.5-6.5 without ECG changes — moderate; insulin/D50 + albuterol + binder; recheck K + ECG q1-2h; cause workup; Known CKD (eGFR <45) + chronic hyperkalemia + ACEI/ARB/MRA — route neph.ckd.core.v1; chronic patiromer or sodium zirconium cyclosilicate for RAAS-inhibitor preservation (RELIEF/AMETHYST/AMBER/HARMONIZE trials — verify).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hyperkalemia symptom-triage (ED workup + cross-engine to syndrome)** (symptom.hyperkalemia-workup.v1).
Phenotype framing: 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.
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute hyperkalemia: membrane stabilization → intracellular shift → elimination (Turk J Emerg Med 2023; ED management)** — step "Membrane stabilization (any ECG change, or K >=6.5)".
1. calcium gluconate 10% 10 mL (1 g) IV over 2-3 min (repeat in 5 min if ECG unchanged); calcium chloride 10% via central line if peri-arrest (cardiac membrane stabilizer, first line) — Does NOT lower K; antagonizes membrane excitability within minutes to prevent dysrhythmia while shift/elimination act (Turk J Emerg Med 2023)

Setting playbook (ed) — ECG severity-anchored stratification; STAT calcium gluconate 1 g IV for K ≥6.5 with ECG changes (peaked T → wide QRS → sine wave) for membrane stabilization; STAT K-shift (insulin 10 U + D50 25 g + albuterol 10-20 mg neb) + bicarbonate if pH <7.2 + binder (patiromer / ZS-9) + furosemide if not anuric + EMERGENCY HEMODIALYSIS for refractory / anuric; pseudohyperK exclusion (repeat with proper technique); cause workup; AVOID Kayexalate chronic (colonic necrosis FDA boxed warning); route to syndrome engine for definitive algorithm (NICE 2020 verify; KDOQI 2020 verify; Cochrane insulin+glucose PMID 26577050 verify)
2. calcium gluconate 10% (membrane stabilization) 1 g IV (10 mL of 10% solution) over 2-3 min; may repeat × 1 if ECG persists; calcium chloride 10% 5 mL via central line (3× more elemental Ca) IV STAT, may repeat — K ≥6.5 with ECG changes (peaked T, wide QRS, sine wave) OR K ≥7 regardless of ECG OR cardiac arrest / peri-arrest (Membrane stabilization — does NOT lower K but prevents arrhythmia; onset 1-3 min, duration 30-60 min; bridge while K-shift drugs work; NICE 2020 verify; KDOQI 2020 verify)
3. insulin (regular) + D50 (K-shift intracellular) Regular insulin 10 U IV bolus + D50 (25 g) IV bolus simultaneously; or D10W 250 mL infusion to avoid hypoglycemia IV STAT — K ≥6.0 with ECG changes OR K ≥6.5 regardless (Drives K into cells via Na/K-ATPase activation; onset 15-30 min, duration 4-6 h; hypoglycemia risk EXTENDS >1 h post-dose — monitor glucose q1h (Cochrane PMID 26577050 verify); reduce insulin to 5 U if glucose <250)
4. albuterol (nebulized) — additive K-shift 10-20 mg nebulized over 15 min (4-8x the asthma dose) inhaled STAT — Adjunct to calcium + insulin/D50 for K ≥6.0 (Beta-2 agonist → cAMP → K shift intracellular; additive 0.5-1 mEq/L drop; onset 30 min; some patients non-responders; caution tachyarrhythmia and CAD)
5. sodium bicarbonate (acidosis correction) 50-150 mEq IV bolus over 15-30 min (50 mEq = 1 amp 8.4%); titrate to pH IV PRN — pH <7.2 with hyperkalemia; severe metabolic acidosis (Reverses acidosis-driven K shift OUT of cells; reduces ~0.5 mEq/L; caution Na load in volume-overload + CHF + cirrhosis; avoid mixing with calcium (precipitation))
6. furosemide IV (renal K excretion) 40-80 mg IV (or higher in CKD up to 200-400 mg); titrate UOP IV PRN — Adequate renal function (UOP) + K removal needed (Loop diuretic increases distal K secretion; useful when UOP is preserved; AVOID in anuria or severe AKI; double dose in CKD due to tubular acid load)
7. patiromer (chronic K binder) 8.4 g PO daily; titrate up to 25.2 g PO daily PO daily — Chronic hyperkalemia management OR RAAS inhibitor preservation (CKD with ACEI/ARB/MRA); also acute moderate K with slower onset acceptable (AMETHYST-DN PMID 25469712, verify) (GI K binder (Ca-polymer); onset hours; preserves cardio-renal benefit of ACEI/ARB/MRA; AE: hypomagnesemia, constipation; takes 6 h apart from other PO meds)
8. sodium zirconium cyclosilicate (Lokelma — ZS-9) 10 g PO TID × 48 h (acute) then 5-15 g daily maintenance PO TID acute / daily maintenance — Acute moderate K + maintenance therapy + RAAS inhibitor preservation (HARMONIZE PMID 31959449 verify; AMBER PMID 27093918 verify) (Selective K binder, faster onset than patiromer (~1 h); FDA approved 2018; less constipation than patiromer; Na load consideration in CHF / HTN)
9. hemodialysis (definitive K removal) Emergent hemodialysis 3-4 h session; ultrafiltration if volume overload extracorporeal emergent / repeat — Refractory K + ECG changes despite medical mgmt OR anuria / ESRD OR severe acidosis / volume overload / pulmonary edema (Removes 25-50 mEq K per session; useful in ESRD, anuric AKI, drug-refractory; access (tunneled catheter or AVF); arrange early — do not delay medical mgmt waiting for dialysis)
10. hydrocortisone (adrenal crisis empiric) 100 mg IV bolus then 50 mg IV q6h × 24-48 h IV q6h — Adrenal crisis suspicion (hyperK + hypoNa + hypotension + steroid history OR hyperpigmentation) (Empiric — do not wait for cortisol; route endo.adrenal-crisis.core.v1; mineralocorticoid effect at high dose helps K)
11. rasburicase (TLS prevention/treatment) 0.2 mg/kg IV × 1 dose (max 6 mg in adults); check G6PD first (hemolysis CI in G6PD deficient) IV single dose — Tumor lysis syndrome (recent chemo + hyperK + hyperuricemia + hyperphosphatemia + hypocalcemia) (Converts uric acid to allantoin (renal-excretable); CI in G6PD deficiency (hemolysis) + pregnancy; route heme.tumor-lysis-syndrome.core.v1)
12. normal saline (rhabdomyolysis aggressive IVF) NS 200-500 mL/h titrate to UOP 200-300 mL/h; total 6-12 L in first 24 h IV continuous — Rhabdomyolysis (CK >5000 + myoglobinuria) (Aggressive forced diuresis to prevent AKI from myoglobin; alkalinize urine pH >6.5 with sodium bicarbonate (controversial); monitor compartment syndrome)
13. discontinue offending medications N/A medication management one-time + ongoing — Drug-induced (ACEI/ARB/MRA/NSAID/trimethoprim/beta-blocker/heparin/tacrolimus/cyclosporine/salt-substitute) (Critical step; substitute non-offending alternative; or continue with binder (patiromer/ZS-9) if HF/CKD benefit > K risk per RELIEF/AMETHYST/AMBER trials)

Non-pharmacologic actions:
- Continuous cardiac monitor + 12-lead ECG q15 min during peak treatment
- Two IV access points; central line for calcium chloride or if vasopressors
- Foley if severe / I/O tracking
- Avoid succinylcholine in at-risk populations (burn, crush, spinal cord, chronic immobility, muscular dystrophy) — use rocuronium
- Avoid additional K-containing IV fluids (LR has 4 mEq/L — switch to NS); avoid salt-substitute KCl
- Avoid Kayexalate (sodium polystyrene sulfonate) chronic use — colonic necrosis risk (FDA boxed warning); patiromer / ZS-9 preferred
- Dietary K counseling (avoid high-K foods: bananas, oranges, tomatoes, potatoes, spinach, salt-substitute)
- Nephrology consult: refractory + dialysis-needed + chronic CKD
- Cardiology consult: severe ECG changes + arrhythmia
- Endocrinology consult: adrenal / type 4 RTA
- Hematology / oncology consult: TLS
- Trauma surgery: rhabdomyolysis with compartment syndrome
- Anesthesia consult: succinylcholine-induced
- Pharmacist consult: medication reconciliation + RAAS-inhibitor preservation strategy

AVOID / contraindication checks:
- AVOID sodium polystyrene sulfonate (Kayexalate), esp. with sorbitol — colonic necrosis risk
- Insulin: monitor glucose q1h for several hours — delayed hypoglycemia common, esp. CKD/no dextrose
- Calcium does NOT lower potassium — never substitute for shift/elimination
- Confirm true hyperkalemia (exclude pseudohyperkalemia: tourniquet/hemolysis/thrombocytosis) before aggressive treatment if no ECG changes

Monitoring

Regimen monitoring:
- continuous cardiac monitor + serial ECG
- recheck serum K at 1-2 h and after each intervention
- glucose q1h x several h after insulin

Setting (ed) monitoring:
- Continuous cardiac monitor + serial ECG q15 min × 2 h then q1h
- K q1-2h until <5.5 then q4h until <5.0
- BMP + glucose q1h × 4 h during insulin/D50 (hypoglycemia risk extends >1 h)
- Ca + Mg + PO4 trend q4-6h
- pH trend q4-6h
- UOP q1h; aim ≥0.5 mL/kg/h
- CK trend if rhabdo
- Repeat plasma K (lithium-heparin) if pseudo suspected
- Cortisol + ACTH stim result + adrenal monitoring
- Albuterol + insulin response (1-2 mEq/L drop expected each)
- Dialysis access + scheduling if refractory

Follow-up plan: 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)
- Close-out criterion: long-term plan in place + follow-up scheduled

Monitoring phase: 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

Disposition

Current setting: ed — ECG severity-anchored stratification; STAT calcium gluconate 1 g IV for K ≥6.5 with ECG changes (peaked T → wide QRS → sine wave) for membrane stabilization; STAT K-shift (insulin 10 U + D50 25 g + albuterol 10-20 mg neb) + bicarbonate if pH <7.2 + binder (patiromer / ZS-9) + furosemide if not anuric + EMERGENCY HEMODIALYSIS for refractory / anuric; pseudohyperK exclusion (repeat with proper technique); cause workup; AVOID Kayexalate chronic (colonic necrosis FDA boxed warning); route to syndrome engine for definitive algorithm (NICE 2020 verify; KDOQI 2020 verify; Cochrane insulin+glucose PMID 26577050 verify)

Disposition criteria:
- Discharge: confirmed pseudohyperK after proper-technique repeat; chronic mild K 5.0-5.4 on outpatient binder + dietary + medication reconciliation
- Observation: moderate K 5.5-6.0 responding to medical mgmt with declining trend
- Ward: K 6.0-6.5 without ECG OR moderate with cause identified + ongoing K-shift therapy + binder
- Telemetry / step-down: K ≥6.5 OR ECG changes OR pending dialysis OR severe acidosis
- ICU: severe symptomatic, ECG changes, acidosis with K shift, dialysis-dependent anuric, TLS, adrenal crisis, rhabdomyolysis with compartment syndrome
- Routes: syndrome.hyperkalemia.core.v1 (definitive algorithm); renal.aki.v1; neph.ckd.core.v1; heme.tumor-lysis-syndrome.core.v1; endo.adrenal-crisis.core.v1

Escalation triggers (move to higher acuity):
- K ≥6.5 with ECG changes → STAT calcium gluconate 1 g IV + insulin/D50 + albuterol + bicarbonate (if acidotic) + binder + dialysis prep
- Cardiac arrest / peri-arrest with hyperK → ACLS + calcium chloride IV + insulin/D50 + bicarbonate + immediate dialysis
- Refractory K despite medical mgmt OR anuria / ESRD → EMERGENCY HEMODIALYSIS
- Severe acidosis (pH <7.0) + hyperK → bicarbonate IV + dialysis
- TLS (recent chemo + lab criteria) → rasburicase + IVF + binder + route heme.tumor-lysis-syndrome.core.v1
- Adrenal crisis (hyperK + hypoNa + hypotension + steroid hx) → hydrocortisone 100 mg IV empiric + route endo.adrenal-crisis.core.v1
- Rhabdomyolysis (CK >5000) → aggressive NS 200-500 mL/h + alkalinize + compartment watch + ICU
- Massive transfusion-related K → switch to washed/fresh PRBC + continuous K monitoring
- Succinylcholine-induced in at-risk population → AVOID future succinylcholine + use rocuronium
- Refractory + RAAS-inhibitor preservation needed → patiromer or ZS-9 + cardiology / nephrology consult

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] K ≥6.5 with ECG changes (peaked T → wide QRS → sine wave → asystole) — STAT calcium gluconate 1 g IV (10 mL of 10%) over 2-3 min for membrane stabilization + insulin 10 U IV + D50 25 g + albuterol 10-20 mg neb + sodium bicarbonate if pH <7.2 + binder + dialysis prep (NICE 2020 verify; KDOQI 2020 verify)
- [LIFE_THREATENING] Cardiac arrest OR peri-arrest with confirmed hyperkalemia — ACLS + calcium chloride 1 g IV via central + insulin/D50 + bicarbonate + IMMEDIATE hemodialysis arrangement
- [LIFE_THREATENING] Hyperkalemia + hyponatremia + hypotension + steroid history OR hyperpigmentation / Addison features — adrenal crisis; STAT hydrocortisone 100 mg IV (empiric) + fluids → route endo.adrenal-crisis.core.v1

Citations

- 2020 NICE hyperkalemia + 2020 KDOQI potassium + Cochrane insulin/glucose + AMETHYST-DN/AMBER/HARMONIZE patiromer + ZS-9 trials + ASCO/ESMO TLS + Endocrine Society adrenal [PMID:37169032](https://pubmed.ncbi.nlm.nih.gov/37169032/)
- Cited evidence (PMID 34958445) [PMID:34958445](https://pubmed.ncbi.nlm.nih.gov/34958445/)

Last reconciled with current guidelines: 2026-05-31.
References
  • 2020 NICE hyperkalemia + 2020 KDOQI potassium + Cochrane insulin/glucose + AMETHYST-DN/AMBER/HARMONIZE patiromer + ZS-9 trials + ASCO/ESMO TLS + Endocrine Society adrenal — PMID:37169032
  • Cited evidence (PMID 34958445) — PMID:34958445