HYPERKALEMIA

(Clinical Diagnosis and Approach)

Endro Haksara, M.Kep

 Objectives

1. Understand diagnosis of hyperkalemia based on

clinical data
2. Understand ECG changes present in hyperkalemic
states
3. Understand treatment/therapy approaches
available for hyperkalemia
 Clinical Scenario
• A 52-year-old man with hypertension and diabetes complains of
weakness, nausea, and a general sense of illness, that has
progressed slowly over 3 days. His medications include a
sulonylurea, a diuretic, and an ACE inhibitor. On examination, he
appears lethargic and ill. His BP is 154/105 mm Hg, HR 70bpm,
temperature 98.6° F, and respiratory rate 22 breaths/min. The
physical examination reveals moderate jugular venous distension,
some minor bibasilar rales, and lower extremity edema. He is
oriented to person and place but is able to give further history. The
ECG shows a wide complex rhythm.
• Laboratory studies performed are significant for potassium 7.8
mEq/L, BUN is 114 mg/dL and creatinine is 10.5.
Diagnostics/Images: ECG
 ECG Changes of Hyperkalemia

• Easily Distinguished ECG signs:

– peaked T wave.
– prolongation of the PR interval
– ST changes (which may mimic myocardial infarction)
– very wide QRS, which may progress to a sine wave
pattern and asystole.
• Patients may have severe hyperkalemia with minimal
ECG changes, and prominent ECG changes with mild
hyperkalemia.
 Analysis

• Diagnosis: Hyperkalemia- Severe

– Classification of Hyperkalemia
• NORMAL: 3.5 to 5.0 mEq/L.
• MILD: 5.5 to 6.0 mEq/L
• SEVERE: Levels of 7.0 mEq/L or greater
• It is important to suspect this condition from the
history and ECG, because laboratory test results may
be delayed and the patient could die before those test
results become available.
 Therapy Approach

• BIG K Drop
B - beta agonists, bicarbonate
I - Insulin
G - Glucose
K - Kayexulate, Calcium
D - Diuretics, Dialysis
1st Line option
Reference: Hollander JC, Calvert CJ. Hyperkalemia. Am Fam Physician 2006; 73:283-90,
Figure 2.
 Clinical Pearls

 Symptoms of hyperkalemia are usually nonspecific,

so risk factors must be used to suspect the diagnosis
 ECG changes consistent with hyperkalemia should
be treated immediately as a life-threatening
emergency. Do not await laboratory confirmation.
 Intravenous calcium is the antidote of choice for
life-threatening arrhythmias related to
hyperkalemia, but its effect is brief and additional
agents must be used
 Comprehension Questions

QUESTION 1:
A 55-year-old man presents in cardiac arrest. A dialysis
fistula is present in the right arm. In addition to
standard ACLS therapies, which of the following is
most appropriate for this patient?
A. 25 g of 50% dextrose, IV push.
B. Sodium bicarbonate, 50-mL IV push.
C. Begin immediate hemodialysis.
D. Calcium gluconate, slow intravenous push.
QUESTION 2:

A 45-year-old man is brought into the emergency center due

to significant dehydration and weakness. His potassium level is
noted to be 7 mEq/L. Which of the following statements is
most accurate regarding his potassium level?
A. Hyperkalemia can usually be diagnosed by symptoms alone.
B. An ECG showing peaked T waves means the patient is stable
and treatment can safely wait until laboratory results are
obtained.
C. Hyperkalemia can mimic a myocardial infarction on the ECG.
D. Hyperkalemia is synonymous with kidney disease.
 QUESTION 3:
Which of the following statements regarding treatment
of hyperkalemia in patients with some renal function is
incorrect?
A. Administration of normal saline may hasten the
excretion of potassium.
B. Administration of furosemide can hasten the excretion
of potassium.
C. The combination of saline with a diuretic is often
indicated because hyperkalemic patients are frequently
dehydrated.
D. Patients with some renal function do not need dialysis
even for severe hyperkalemia.
QUESTION 4:
A patient with severe renal disease is found to have
hyperkalemia, with tall, peaked T waves on ECG.
Vascular access cannot be readily obtained, but vital
signs are stable. Which of the following would be
appropriate temporizing measures?
A. Inhaled albuterol 2.5 mg in 3 mL saline
B. Oral sodium bicarbonate with rectal sodium
polystyrene sulfonate
C. Inhaled albuterol 20 mg, with oral or rectal sodium
polystyrene sulfonate, 30 g
D. Oral dextrose 25 g
 References

• Evans KJ, Greenberg A. Hyperkalemia: a review. J Intensive

Care Med. 2005 Sep-Oct;20(5):272-290.
• Kamel KS, Wei C. Controversial issues in the treatment of
hyperkalaemia. Nephrol Dial Transplant. 2003;18:2215-2218.
• Sood MM, Sood AR, Richardson R. Emergency management
and commonly encountered outpatient scenarios in patients
with hyperkalemia. Mayo Clin Proc. 2007 Dec; 82(12):1553-
1561.
• Hollander JC, Calvert CJ. Hyperkalemia. Am Fam Physician
2006; 73:283-90