Death by Bananas
The Management of Hyperkalaemia
Dr. Kiaran Flanagan, Clinical Lead Acute Medicine UHCW
June 2012
Case 1
• Patient comes into ED referred by GP for high potassium of 6.7
• You see the notes in the SIFT tray
• What do you do? ...
How to manage
• Pick up notes and PUT STICKER ON THE LIST
• ABCDE
• What are you likely to find?
• What urgent investigation do you need to make a treatment decision?
• What action would you take if – 1. Normal
– 2. Abnormal
What next?
• History...
• Examination...
• Further tests
• What are you looking for?
What next...
• Senior review?
• Actions you should recommend...– Drugs
– Monitoring
– Admit/ Discharge
– Further checks
– Anticipated future actions
– How will you make this happen?
Case 2
• Patient on the ward
• ATSP – unwell, vomiting
• Day 2 of admission – post op R hemicolectomy
• What do you do?
What do you do?
• ABCDE
• Investigations?
• Monitoring...
Patient hyperkalaemic
• What else do you look for?
• What test needs to have been done?
• What treatment do you need to give?
Recheck K at 3 hours
• Still high...
• What next?– Treatment
– Advice
– Monitoring
Recheck K at 6 hours
• Still high...
• What do you do?– Treatment
– Monitoring
– Ask for help
• Who
• What will you tell them and how?
• What for
Case 3
• Patient – Medical ALERT to Resus
• Drowsy
• High glucose
• What do you do????
What do you do?
• ABCDE
• Urgent tests
• What is the diagnosis?
• How do you manage?
Case 4
• Cardiac Arrest Call
• PEA
• What do you think about?
Hyperkalaemia in cardiac arrest
• What do you give?
Case 5
• Called to ward 1, pt unwell
• Low BP, low glucose, high potassium
• What do you do?– Assessment
– Further tests?
– Working diagnosis
– Treatment?
Causes of Hyperkalaemia• Decreased or impaired potassium excretion – renal
failure, potassium-sparing diuretics, urinary obstruction, sickle cell disease, Addison disease, and systemic lupus erythematosus (SLE)
• Additions of potassium into extracellular space - potassium supplements (eg, PO/IV potassium, salt substitutes), rhabdomyolysis, and hemolysis (eg, blood transfusions, burns, tumor lysis)
• Transmembrane shifts (ie, shifting potassium from the intracellular to extracellular space) - acidosis and medication effects (eg, acute digitalis toxicity, beta-blockers, succinylcholine)
• Factitious or pseudohyperkalemia - improper blood collection (eg, ischemic blood draw from venipuncture technique), laboratory error, leukocytosis, and thrombocytosis
Causes
• Ineffective elimination– Kidneys
– Drugs
– Endocrine
• Excessive release from cells– Injury
– Metabolic
• Excessive intake– Lethal Injection
• Pseudo
ECG Changes
How does it affect the heart?
• Hyperkalemia results in:
• Inhibition of atrial myocardial depolarization.
• Slowing of heart rate.
• Prolonging QRS duration; complexes may become bizarre.
• Also known as atrial standstill.
• Rhythm called sinoventricular rhythm.
• The ECG is a poor substitute for serum potassium levels to determine
the degree of abnormality
ECG Changes
• From reduction of P wave amplitude and prolongation of PR
interval to absence of P waves altogether.
• Increase of QRS duration.
• Increase of QT duration.
• Slowing of heart rate.
• T waves become tall and spiked.
• Decreased R wave amplitude
ECG Changes
3 Principles of Treatment
• Stabilise myocardium
• Move it into cells
• Increase elimination
Dextrose - Insulin
• How does it work?
• How long for?
• How do you give it?
• What is the dose?
• Other considerations...
Calcium Gluconate
• How does it work?
• How long for?
• How do you give it?
• What is the dose?
• Other considerations...
Sodium Bicarbonate
• How does it work?
• How long for?
• How do you give it?
• What is the dose?
• Other considerations...
Calcium Resonium
• Hmmm....
More controversial
• Salbutamol
• Furosemide
Protocols
• If K > 6 mmol– Calcium Resonium
– Unless – Rising fast/ patient septic then treat as below
• If K > 6.5 – normal ECG– Dextrose Insulin
– Calcium Resonium
Protocols
• If K > 6.5 – abnormal ECG or
• If K > 7
– Calcium Gluconate
– Dex Insulin
– Salbutamol
– Sodium Bicarbonate
– RRT
Important Bits...
• POTENTIAL LIFE THREATENING EMERGENCY
• TREAT IF INDICATED
• TRUST BUT VERIFY
• RECHECK
• CARDIAC MONITORING
• EXPERT HELP
• PREVENTION
