Hyperkalemia Tutorial

electrolyte emergency Hyperkalemia is the most dangerous acute electrolyte emergency

Refer to ED lecture series and self directed workbooks Hyperkalemia Which symptom is not generally an indication of hyperkalemia? Generalised fatigue Weakness Increased respiratory rate Paralysis Palpitations Refer to ED lecture series and self directed workbooks

Increased Respiratory Rate Which symptom is not generally an indication of hyperkalemia? Generalised fatigue Correct. - The symptoms of hyperkalemia are related to impaired neuromuscular transmission. Weakness Increased respiratory rate Paralysis Press the other options to learn more or select next Palpitations Next Refer to ED lecture series and self directed workbooks

Generalised Fatigue & Weakness Which symptom is not generally an indication of hyperkalemia? In hyperkalemia neurologic examination may reveal diminished deep tendon reflexes or decreased motor strength Generalised fatigue Weakness Increased respiratory rate Paralysis Press the other options to learn more or select next Palpitations Next Refer to ED lecture series and self directed workbooks

Paralysis Which symptom is not generally an indication of hyperkalemia? Generalised fatigue The earliest findings are paresthesias and weakness, which can progress to paralysis affecting respiratory muscles. Weakness Increased respiratory rate Paralysis Press the other options to learn more or select next Palpitations Next Refer to ED lecture series and self directed workbooks

Palpitations Which symptom is not generally an indications of hyperkalemia? Generalised fatigue In a patient with hyperkalemia cardiac examination may reveal extrasystoles, pauses or bradycardia Weakness Increased respiratory rate Paralysis Press the other options to learn more or select next Palpitations Next Refer to ED lecture series and self directed workbooks

Causes of Hyperkalemia Which of the following is not one of the causes of hyperkalemia? You Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Trauma

Press the other options to learn more or select next Cushing’s Syndrome Which of the following is not one of the causes of hyperkalemia? You Correct! - Cushing’s syndrome describes the signs and symptoms of prolonged exposure to high levels of cortisol. - Cushing’s can cause hypocalceamia. Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Press the other options to learn more or select next Trauma Next

Press the other options to learn more or select next Pseudohyperkalemia Which of the following is not one of the causes of hyperkalemia? You - The most common cause of hyperkalemia is haemolysis of the sample.. - Other causes of pseduohyperkalemia include leukocytosis or thrombocytosis. Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Press the other options to learn more or select next Trauma Next

Drugs Which of the following is not one of the causes of hyperkalemia? Some drugs will cause potassium redistribution or decreased excretion. Redistributing examples; - Beta blockers - Digoxin overdoes - Succinylcholine Decreased excretion examples; - NSAIDs - Cyclosporine - Potassium sparing diuretics ***Especially in the elderly and/or those with minor renal insufficiency*** You Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Trauma Press the other options to learn more or select next Next

Press the other options to learn more or select next Renal Failure Which of the following is not one of the causes of hyperkalemia? Decreased glomerular filtration rate or a defect in tubular secretion will lead to diminished potassium excretion You Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Press the other options to learn more or select next Trauma Next

Metabolic Acidosis/DKA Which of the following is not one of the causes of hyperkalemia? - Hyperkalemia impairs the NH4+ excretion though the proximal tubule and the reduction of NH4+ reabsorption in the thick ascending limb. This results in reduced medullary interstitial [NH3] and a decrease in net renal acid secretion. - This is a common feature in diabetes and a number of other conditions associated with underproduction of renin or aldosterone. You Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Trauma Press the other options to learn more or select next Next

Press the other options to learn more or select next Trauma Which of the following is not one of the causes of hyperkalemia? Trauma can result in hyperkalemia via cell death; - Rhabdomolysis - Internal haemorrhage - Burn - Crush - Haemolysis You Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Press the other options to learn more or select next Trauma Next

Hyperkalemia With suspected hyperkalemia should you first: Perform an ECG? Wait for blood test? Start treatment?

Hyperkalemia = ECG With suspected hyperkalemia should you first: Next YES! HyperK = ECG If a patient arrives with a K+ of 9 mmol/L is it an emergency? Was it a haemolysed sample? If they have a sine wave on ECG, then yes. Perform an ECG? Wait for blood test? Start treatment? ECG Changes Serum Level Tall Peaked T 5.5-6.5 Loss of P Wave 6.5-7.5 Widened QRS usually >8 Press the other options to Learn more or select next Next

Press the other options to learn more or select next Wait for blood tests With suspected hyperkalemia should you: Perform an ECG? Consider the time delay for repeat blood collection if the first sample is haemolysed. An elevated result from the iSTAT may have been from an ischaemic blood draw. Wait for blood test? Start treatment? Press the other options to learn more or select next Next

Select another option or select next Start treatment With suspected hyperkalemia should you: Perform an ECG? A tough call if you don’t know if you are facing a true hyperkalemia emergency. Wait for blood test? Start treatment? Select another option or select next Next

A hyperkalemia Emergency Is defined as…. A wide QRS Next

ECG Changes seen in Hyperkalemia Tall Peaked T-Waves Prolonged P-R Interval Loss of P wave Widening of QRS Sine wave Next

When the T wave is bigger than the QRS think Hyperkalemia Next

Widening of the QRS now a true emergency Next

Treatment Which of the following is considered the best option for treating hyperkalemia? Calcium Gluconate Glucose & Insulin Bicarbonate Beta Agonist Volume

Treatment – Calcium Gluconate Which of the following is considered the best option for treating hyperkalemia? - Only use in a true hyperkalemia emergency (widen QRS). - Tricks the cell by re-creating the electrical potential, narrowing the QRS. - Does not affect the potassium level and is only temporary (5-20mins). ***Only give Calcium Gluconate if wide QRS*** Calcium Gluconate Glucose & Insulin Bicarbonate Beta Agonist Volume Press the other options to learn more or select next Next

Treatment – Glucose & Insulin Which of the following is considered the best option for treating hyperkalemia? Best Option! - Stimulates glucose pump - Glucose carries K+ in, drives Na out - Drops K by up to 1.0mmol/L - Works over 20-60 minutes - Effective within 20 minutes Glucose: IV 50g as 50% solution or 500ml of D10W solution Insulin: regular IV 10 units Calcium Gluconate Glucose & Insulin Bicarbonate Beta Agonist Volume Press the other options to learn more or select next Next

Treatment – Bicarbonate Which of the following is considered the best option for treating hyperkalemia? - Only use if the patient is acidotic. - A good option for a patient with renal failure. - Dose is 1-2 ampules Calcium Gluconate Glucose & Insulin Bicarbonate Beta Agonist Volume Press the other options to lean more or select next Next

Press the other options to lean more or select next Treatment – β-agonist Which of the following is considered the best option for treating hyperkalemia? - Inhaled beta agonist have been proven to be effective - Can lower serum K+ 0.5 – 0.66mmol/L - Salbutamol 5mg can be given via a nebulised (10-20mg in 4ml saline) or IV infusion (0.5mg) - Beware of causing tachycardia Calcium Gluconate Glucose & Insulin Bicarbonate Beta Agonist Volume Press the other options to lean more or select next Next

Press the other options to learn more or select next Treatment – Volume Which of the following is considered the best option for treating hyperkalemia? - Helps restore cellular Na-K gradient - Especially good in dehydrated patients - Especially bad in CHF/CRF - Beware pulmonary edema Calcium Gluconate Glucose & Insulin Bicarbonate Beta Agonist Volume Press the other options to learn more or select next Next

Steps in treating hyperkalemia Reverse electrical effects – treat wide QRS Calcium Gluconate Drive potassium into the cells Glucose & Insulin Beta agonist mask Bicarbonate – only if acidotic Consider saline bolus Removes potassium from the body Forced diuresis Dialysis Next

Summary Number 1 cause of hyperK = Haemolysis Hyperkalemia = ECG Only give calcium if… wide QRS Bicarb only if… patient is acidotic Secure the ABC’s

Resources Journal of the American Society of Nephrology (http://jasn.asnjournals.org/content/20/2/251.full ) Medscape (http://emedicine.medscape.com/article/766479-overview ) USCEssentials 2009-04 ‘Kyper K in 20 min’ Dr Corey Slovis http://enotes.tripod.com/hyperkalemia.htm

Further reading