Cite this post as:
Guest Author. EMCrit – Critical Hyperkalemia by H. Pendell Meyers, EMCrit Intern. EMCrit Blog. Published on November 28, 2017. Accessed on February 14th 2025. Available at [https://emcrit.org/emcrit/critical-hyperkalemia/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: November 28, 2017
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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Pendell Meyers, welcome aboard. i am sure the midwest will be a colder place while you are on the east coast. have been an admirer and on line student of Steve Smith for a while now, and i am glad that scott has you with the emcrit team now. this review is strong, and excellent. have not yet gone to your links cited, but i still dont know the “truth” regarding kayexalate and sodium bicarb. an emedhome lecture i heard a few months ago said they were useless and potentially dangerous. recently a hospital (i think in maryland) settled for… Read more »
Thanks Tom! I also have not yet done my own deep dive on kayexalate, but all of the smart people I trust who have done so seem to come to that same conclusion: not effective and rarely also dangerous. I did not know about that case with the settlement, good to know!
Great article Pendell, much appreciate your work sorting out the lit reviews and stats for us. Lots of things in here I can take to the bedside today. I wish I had read your pearl “beware the tall T wave falsely doubling the HR on monitor” some time ago, that one burned us a while back. The patient had only been in department a short time, and the rhythm was quite insidious because the wide/bizarre QRS didn’t look too different from the T wave on the bedside monitor- we only discovered the true HR (30’s) when BP plummeted, prompting careful… Read more »
Interesting case, thanks Patrick! I’ve had a single case like that as well. It is rare but really makes you wish you had seen it prospectively. Defib pads seem reasonable to me at a certain point along the spectrum. I think pads for any ECG change would be overkill, but unfortunately like I showed in the case above, we do have one recorded case where a patient with only T-wave peaking went into VF arrest (presumed hyperkalemic, no other source found after cardiac cath and other workup) after only 5-10 minutes. I used to think that hyperkalemic patients mostly all… Read more »
Pendell – great article and valuable pearls. Agree that we probably underestimate the degree to which hyperK underlies many lethal dysrhythmias/peri-arrest presentations.. Excited to see you’ve joined the EMCrit team and glad to see you’re doing well!
Christian, thanks for the kind words and I’m sure you’re doing fantastically as always. I might not be in EM at all if not for you and Matt, thanks again!
Great post! A small thing, but I noted an inaccuracy; the single case fatality in the Dodge et. al. (1953) study resulted from administration of only 200 mEq of KCl, not over 400. Thanks for this great analysis!
Drew, thanks for fact checking. My copy of the article states “15 grams” of potassium was given as a single oral dose. I don’t frequently convert grams to mEq, but on repeating my calculation I’m getting 384 mEq. So maybe I exaggerated just a little. If I’m calculating this wrong please help, teach, and explain! Thanks for the sharp eye and sorry in case this was fake news.
If it’s 15 grams of KCl instead of 15 grams of K then you’re probably right, only ~1/2 of the total mEq would be K. Roughly 200. I see your point. Good catch.
How often is Calcium Gluconate enough to save lives in hyper kalmia and how safe is it ?
How many deaths now in Reduced Ejection Fraction Heart Failure on ACE I /ARB -B Blockers and Spironolactone .
This combination is being insisted upon by expert advice for REF-HF
Welcome Pendell and excellent post! I do have one question regarding the treatment of hyperkalemia. I’m confused as to why Lactated Ringer’s would be the fluid of choice in the setting of hyperkalemia, being that a liter of LR contains about 4 mEq of K. I would think a fluid containing no potassium would be preferable? Thanks for the great read!
Quinten
Quinten, see reference #11 on the article- PulmCrit did a post on this issue a while back. Since the concentration of K in Lactated Ringer’s is 4 meq/liter, infusion of LR will pull the serum K concentration towards 4. Avoiding NS is also a reasonable move since large volume NS creates hyperchloremic acidosis, which shifts K out of the cells into the serum.