1. A 48-year-old man presented with diarrhea, nausea and vomiting for 3 days. His ECG was normal and potassium was 6.1. 2. As his ECG was normal and potassium was only mildly elevated, treatment was not urgently needed. Close monitoring and hydration would be sufficient. 3. If his potassium rose further or ECG changes developed, treatment like glucose/insulin infusion would be considered to enhance potassium excretion through the kidneys.

1. Hyperkalemia – Pathophysiology
& Treatment in ER
- Dr Varun Patel

3. Normal levels? – 3.5 to 5.0 mmol/l

4. Concept: Change in Potassium
levels
If the change is slow, then kidneys adapt to the change and excrete
more potassium over time and hence it is less dangerous
If change is fast, then kidneys have no time to adapt and can lead
to detrimental cardiac issues

5. Cardiac Action Potential

6. Hyperkalemia and Cardiac AP

7. Mechanism of Action of Aldosterone?

9. Principal cell physiology
Things that drive excretion of
more K –
1. High Na in tubules
2. High flow rate
3. Increased delivery of Anions
like HCO3-, Amino acids

10. Potassium sparing diuretics &
Aldosterone

11. Hyperkalemia- Questions
When to suspect Hyperkalemia?
What are the ECG changes in Hyperkalemia?
What are the indications to give Calcium in treatment of Hyperkaelmia?
Is Calcium strictly contraindicated on patients with digoxin?
Which is better Calcium gluconate or Calcium Chloride?
Is there any role of K Bind in ED?
Which fluids are the best to eliminate Potassium from kidneys?
Should we use laxatives to increase excretion of Potassium from GI tract?
Should Bicarbonate be ever used to treat Hyperkalemia?
How soon can we expect Potassium to be corrected after giving treatment?

12. Hyperkalemia- Questions
When are we supposed to give Beta Agonists?
Is there are a role of Intra arrest Dialysis for Hyperkalemia?
How to avoid Hypoglycemia in GI Infusion?
Can we use Furosemide in treatment of Hyperkalemia?

13. Case 1-
A 48yr old male comes to ED with gradual onset Diarrhea, Nausea
and Vomiting over 3 days. No travel history, no Malena, no
gallstones, no pancreatitis, no chest pain, no breathlessness, non
smoker and non drinker. His vitals are normal and abdomen is soft
and non tender. ECG shows peaked T waves with no ST-T
changes. His first HsTropI is normal and K is 6.3 and Creat 1.5.
Would you treat this patient?
What would you give this patient?

14. Some Tips-
Level of Potassium has no correlation with the symptoms of a
Patient
The faster the rise, more likely that patient will be symptomatic.
When to suspect Hyperkalemia? - GI issues like vomiting, diarrhea
and Neurosymptoms like non specific deficits in neurology.
Always rule out Pseudohyperkalemia (sample collection errors) -
They represent 20% of Hyperkalemia
Always take a 12 lead ECG for suspected Hyperkalemia.

15. Causes of Hyperkalemia?

16. Causes of Hyperkalemia?

18. Drugs causing Hyperkalemia

19. Drugs causing Hyperkalemia

20. Digoxin Toxicity

21. Trimethoprim

22. Calcineurin Inhibitors

23. PseudoHyperkalemia

24. ECG changes- HYPERKALEMIA
Flattening of P waves
Peaked T waves
Widening of QRS with slurring of upslope of S waves
Merging of QRS into T waves to form Sine waves
Note- ECG changes do not necessarily correlate with the level of
Potassium
Hyperkalemia is a ‘Great Imitator in ECG’

28. Is this V Tach? How many of you will shock
this patient of unstable? (Patient’s K on VBG
– 7.5)

29. After Potassium correction and
Calcium infusion – 30minutes later

30. Patient deteriorated – Intubated and
Cardioversion done

31. Sedative of Choice in Above patient
for Cardioversion?

32. Diagnostic Evaluation of
Hyperkalemia

33. Treatment of Hyperkalemia-
Stabilise Cardiac Membrane
Shift Potassium intracellularly
Removing Potassium with Dialysis or Hydration

34. Which patients should receive
treatment?

35. Potassium levels-
5 to 6.5 without ECG changes
5 to 6.5 with ECG changes
Potassium above 6.5

36. Potassium levels-
5 to 6.5 without ECG changes (only enhance excretion with
Hydration)
5 to 6.5 with ECG changes (shift and stabilise membrane)
Potassium above 6.5 (shift and Stabilise membrane)

37. Is there a role of K Bind (Calcium/Sodium
polystyrene Sulphonate) in ED?

39. How to give Glucose Insulin
infusion?
Give 50mls of D50% with 10 units of Insulin over 15min rapid
infusion
Check sugar at 0, 15, 30 minutes and then every hour up to 6 hrs
Start IV D5% as maintainence to avoid Hypoglycemia (look out for
fluid overload)
Correct Hypoglycemia if any.

40. Beta agonists like Salbutamol-
It reduces Potassium by 1.2 mmol per hour.
Give high doses – 20mg of Nebulised Salbutamol
It works synergistically with Insulin and Glucose
Do not use as a monotherapy (Does not work alone)

41. When to give Salbutamol?

42. Salbutamol only after GI infusion-
Salbutamol transiently increases Potassium by 0.4 mmol
Hence only given after giving GI drip to avoid potassium rise
leading to cardiac side effects.

43. Do we give Sodium Bicarbonate in ED
to treat Hyperkalemia?

44. Sodium Bicarbonate in
Hyperkalemia-
No role in ED management of Hyperkalemia
Only indication is Non Anion gap metabolic Acidosis (Renal Tubular
Acidosis). When have you last made this diagnosis?
Always wait for Nephrology reference and let them decide.

45. Elimination of potassium-
Always put a Foleys Catheter
Hydration is the key (IV Crystalloids – At least 2 litres)
No role for Diuretics (Exceptions – As given below)

47. Which fluid to give for Hyperkalemia?

48. Always Normal Saline

49. How fast does treatment work?
Repeat potassium in 1 hour as most of treatments correct
potassium significantly in 1 hour

51. Does GI elimination have a role in
ED?
Why not to be used?
Laxatives are uncomfortable
Does not drop potassium fast
There is usually only 1 toilet in the ED 😂
If needed- Best laxative is PEG 33/50 – Polyethylene Gylcol

52. Case 2-
A 67 yr old female with CKD on MHD, comes weak and uneasy to
ED, You order an ECG which shows bizarre looking wide QRS.
VBG is done which shows Potassium is 7.4. How would you treat
this patient?

53. Stabilise the membrane
Shifting the Potassium
Nephrology opinion
Dialysis, Dialysis, Dialysis

54. When to give Calcium ?
Cutoff- 6.5 (Theoretically can lead to rapid deterioration into
Arrhythmia)
Mechanism of Calcium in Hyperkalemia? (Speed up
Depolarisation). Hence if ECG is normal, Calcium has no effect. It
is just prophylactic
Calcium is actually effective only if there is wide QRS

55. Calcium chloride vs Calcium
Gluconate?

56. Calcium Chloride vs Calcium
Gluconate
Calcium chloride if extravasated in tissues can lead to Necrosis
Calcium Gluconate should be given in high doses (At least 3
ampules- 30ml)
Start with 1 ampule (1g) – Repeat ECG – Whenever needed repeat
1g
Calcium chloride is only reserved for patients in Cardiac Arrest

57. Is calcium contraindicated in Patients
with Digoxin toxicity?
Recommendations state that you can still give Calcium Gluconate
in Hyperkalemia with Digoxin Toxicity – Give it as a slow infusion
over 20mins
Avoid Calcium in patients with normal ECG in Digoxin Toxicity

60. Case 3-
An 80yr old female comes to ED with decreased consciousness
and history of vomiting and loose stools since 4 days. K/c/o of
ESRD, HTN, IHD with MI in past. ECG shows wide bizarre looking
QRS with bradycardia. VBG shows severe metabolic acidosis PH-
6.9 and K-9.1. Patient arrests in front of you, how would you treat
her?

61. Manage ABCs
Give Calcium chloride 1amp
Give Sodium Bicarbonate
Give Epinephrine (Low dose) – it can bind Beta receptors and give
similar action as Beta 2 agonists
Intra arrest Dialysis? – Usually practically not possible
After ROSC –Calcium acts only for 30mins and hence, as soon as
possible arrange Dialysis and till then use Shifting strategies. Keep
Calcium ready bedside.

62. Case 1-
A 48yr old male comes to ED with gradual onset Diarrhea, Nausea
and Vomiting over 3 days. No travel history, no Malena, no
gallstones, no pancreatitis, no chest pain, no breathlessness, non
smoker and non drinker. His vitals are normal and abdomen is soft
and non tender. ECG is normal with no ST-T changes. His first
HsTropI is normal and K is 6.1 and Creat 1.5.
Would you treat this patient?
What would you give this patient?