ekg

Hyperkalemia Master Class

Dr. Levin presented a case of a patient who had “changes on tele” and ended up having this EKG:

Yikes! He had a normal EKG prior.   Let’s point out some of the scary changes here:   1. Where are the P waves? are they gone entirely or just very small?  2. Are those T waves peaked?  3. Why is the QRS suddenly so wide?

Yikes! He had a normal EKG prior.

Let’s point out some of the scary changes here:

1. Where are the P waves? are they gone entirely or just very small?

2. Are those T waves peaked?

3. Why is the QRS suddenly so wide?

Labs were obtained and he had a K of 7.6!

Here’s our approach to the evaluation of hyperkalemia:

(Content adapted from the excellent curbsider’s podcast: Hyperkalemia Master Class)

  1. Does it make sense for this patient to have hyperkalemia?

    • Is the sample hemolyzed?

    • If not, consider causes of pseudohyperkalemia: ie very high WBC count like in CLL, thrombocytosis (PLT >1,000,000), anything that increases the likelihood of the cells lysing in the phlebotomy tube

  2. Rule out urinary obstruction (if anyone can comment on the mechanism of this, please do in the comments section! For a prize of resident education …okay and some candy too)

  3. Evaluate for hyperglycemia (can ca

When do we treat?

  • In one study by Einhorn et al:

    • Potassium 5.5 OR for death

    • Potassium >6, OR for death 31

  • Consider treating (ie shifting etc) when K>6.0 + EKG changes or >6.5 regardless of EKG changes

What do we treat ACUTELY with?

  • Calcium for membrane stabilization (Calcium gluconate typically but Calcium chloride is also an option)

  • Insulin & glucose (Don’t forget to recheck glucose q30-60min after for up to 3-4 hours!)

  • Beta agonist (The dose of albuterol for shifting is 20mg. To give you an idea, the dose of a standard albuterol neb is 2.5mg)

  • Bicarb (typically reserved for when the cause of the hyperkalemia is acidosis. Keep in mind also that bicarb will shift calcium into cells— something you may not want in the setting of EKG changes)

But how do we get it out of the body?

  • If they can pee, urine is the best bet (lasix or lasix + IVF so minimize the adverse side effects of the diuretics)

  • Reserve kayexylate (or SPS) for those who cannot urinate or those who have chronic hyperkalemia. AVOID this in patients w/ CKD or ESRD, s/p renal transplantation or any kind of bowel obstruction/decreased bowel motility (refer to our recent blog post here

Thanks for reading! If you’re enthralled and need to know MORE about hyperkalemia, we highly recommend the hyperkalemia master class episode of the Curbisider’s Podcast here