1. Hyperkalemia Tutorial

2. electrolyte emergency
Hyperkalemia is the
most dangerous acute
electrolyte emergency

3. 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

4. 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
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Palpitations
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Refer to ED lecture series and self directed workbooks

5. 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
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Palpitations
Next
Refer to ED lecture series and self directed workbooks

6. 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
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Palpitations
Next
Refer to ED lecture series and self directed workbooks

7. 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
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Palpitations
Next
Refer to ED lecture series and self directed workbooks

8. 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

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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
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Trauma
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10. 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
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Trauma
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11. 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
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learn more or select next
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12. 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
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Trauma
Next

13. 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
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more or select next
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14. 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
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Trauma
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15. Hyperkalemia With suspected hyperkalemia should you first:
Perform an ECG?
Wait for blood test?
Start treatment?

16. 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
Loss of P Wave
Widened QRS usually >8
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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?
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18. 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?
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19. A hyperkalemia Emergency
Is defined as….
A wide QRS
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20. ECG Changes seen in Hyperkalemia
Tall Peaked T-Waves
Prolonged P-R Interval
Loss of P wave
Widening of QRS
Sine wave
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21. When the T wave is bigger than the QRS think Hyperkalemia
Next

22. Widening of the QRS now a true emergency
Next

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

24. 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
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25. 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 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
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26. 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
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Next

27. 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
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28. 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
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Next

29. 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

30. 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

31. Resources
Journal of the American Society of Nephrology ( )
Medscape ( )
USCEssentials ‘Kyper K in 20 min’ Dr Corey Slovis

32. Further reading