Hyperkalemia
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>6.0 mmol/L
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EKG changes (not necessarily in order, especially if chronic renal failure patient)
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Peaked T waves
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PR prolongation
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Short QT (<350 ms)
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Widened QRS
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Flat P waves
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Heart Block
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Sine wave
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V. Fib.
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Treatment: Stabilize, Shift, Excrete
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Stabilize: Calcium stabilizes myocardial membrane with onset in 15-30 minutes.
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Calcium gluconate IV
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10 ml of 10% solution over 10 minutes
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may cause hypotension
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Calcium chloride contains 3x more calcium
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10 ml of 10% solution (1 gram) IV over 1-2 minutes
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Scleroses veins and extravasation can cause necrosis. Be sure IV is good, preferably central access.
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Digoxin “Stone Heart” syndrome in patient given IV calcium is best addressed here.8
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Shift: Several agents can shift potassium into the intra-cellular compartment.
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Insulin – 10 units regular IV (5 units IV if renal insufficiency 5)
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Administer with glucose if serum glucose < 300 mg/dL
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Glucose 25-50 gm IV (D50 = 50% dextrose in a 50 ml syringe = 25 grams)
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Onset: 30 minutes
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Duration of effect 4-6 hours, lowers level by 1 mmol/L
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Albuterol nebulized 5-20mg (note: typical dose for bronchospasm is 2.5mg /3ml)
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Onset: 30 minutes
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Duration: 2 hours
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Sodium Bicarbonate IV (50 ml of 8.4% = 1 amp)
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Only effective if patient is acidotic
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Given over 5 minutes
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Onset 30-60 min
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Duration 1-2 hours
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Excrete:
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Lasix diuresis, 40-80 mg IV if urine output is proven
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Kayexalate (sodium polystyrene sulfonate) 30 gm orally
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There is increasing opinion that kayexalate is not as effective as we believe 6,7
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Given risk of necrotizing colitis, rectal use is best avoided.
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IV hydration / resuscitation for patients with dehydration, DKA, sepsis, rhabdomyolysis, etc.
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Hydrocortisone therapy for patients with adrenal insufficiency
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Dialysis
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Symptoms
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Lethargy and fatigue
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Muscle weakness
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Tingling
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Vomiting
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Shortness of breath
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Palpitations
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Chest pain
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Causes
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Renal failure
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Addison’s disease (adrenal insufficiency)
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ACE inhibitors
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Beta blockers
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Dehydration
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Trauma / burns / tissue destruction
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Excessive oral intake
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References:
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Tse G, Chan YW, Keung W, Yan BP. Electrophysiological mechanisms of long and short QT syndromes. Int J Cardiol Heart Vasc. 2017;14:8-13. PubMed Full Article
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Larue HA, Peksa GD, Shah SC. A Comparison of Insulin Doses for the Treatment of Hyperkalemia in Patients with Renal Insufficiency. Pharmacotherapy. 2017;37(12):1516-1522. PubMed
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Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective?. J Am Soc Nephrol. 2010;21(5):733-5. PubMed
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Erickson CP, Olson KR. Case files of the medical toxicology fellowship of the California poison control system-San Francisco: calcium plus digoxin-more taboo than toxic?. J Med Toxicol. 2008;4(1):33-9. Full Text