How do you treat Hyperkalemia?

Dr. Jordyn Johnson

Editor: Omar Lopez MS3

Definition of Hyperkalemia?


  • Lab errors: Hemolysis (not reported at LCM), Sampling, handling/transport

  • Pseudohyperkalemia (high platelets, WBC’s or RBC’S)

  • Thrombocytosis, Blood transfusion

  • Lupus

  • Medications: heparin, lithium, paralytics, penG, antifungals

EKG Changes

Nontraditional ECG changes:

  • T wave inversions and pseudonormalizations

  • bundle branch, bifascicular, sinoatrial exit, and atypic bundle branch blocks

  • ST depressions and elevations

HyperK mimics:

  • left ventricular hypertrophy

  • early benign repolarization

  • acute coronary ischemia

Why is Hyperkalemia dangerous?

  • K above 5.1 in MI is an independently significant risk factor for mortality.

  • Repeated episodes of hyperkalemia also significantly increased mortality in admitted patients

Temporary vs Definitive Tx


Stabilization of cardiac membrane (Calcium gluconate)

Redistribution of potassium (insulin and albuterol)

Elimination of potassium (diuretics)

Long term:

Address underlying causes

Diet - least emphasized but an important factor

Adverse Effects

  1. Calcium infusion:

    1. Heart block in patients with digoxin-induced hyperkalemia

    2. Acute dermal calcifications.

    3. Theoretic risk of metastatic vascular calcifications.

  2. Albuterol: Hypoglycemia and tachycardia

  3. Diuretics:

    1. dysnatremias, hypomagnesemia

    2. nephrolithiasis

  4. Sodium Bicarbonate:

    1. Acute pulmonary edema

    2. May precipitate acute hyperosmolarity including case reports of central pontine myelinolysis.

    3. Worsening of AKI and mortality in patients undergoing cardiac surgery

Newer potassium exchange resins can induce hypomagnesemia, hypercalciuria, and even edema at high doses

Changes of Practice

  1. Sodium Bicarbonate: It has been found that isotonic really only works for patients with metabolic acidosis and is inappropriate if the patient is also fluid overloaded. Hypertonic sodium bicarbonate or “amp of bicarb” has been proven not to work.

  2. Kayexalate: Cochrane review found there to be no significant studies supporting its use. Given its risk profile including GI disturbances, significant electrolyte abnormalities and, when given alone or with cathartics, bowel necrosis its use has been decreased.

EMCrit: “Neither kayexalate nor patiromer has been proven to lower potassium acutely. Neither one currently has a role for emergent therapy of hyperkalemia.”


  1. Farkas, J. (2022, June 11). Hyperkalemia. EMCrit Project. Retrieved September 22, 2022, from

  2. Hollander-Rodriguez, J. C., & James F. Calvert, J. (2006, January 15). Hyperkalemia. American Family Physician. Retrieved September 22, 2022, from,be%20given%20intravenous%20calcium%20gluconate.&text=Acutely%20lower%20potassium%20by%20giving,agonist%20by%20nebulizer%2C%20or%20both.&text=Total%20body%20potassium%20should%20usually,sodium%20polystyrene%20sulfonate%20(Kayexalate).

  3. Malone, D. J. (2015, November). Taking a second look at Kayexalate. Hospital pharmacy. Retrieved September 22, 2022, from

  4. sbord1. (2021, August 2). Elevated potassium: Let's rethink kayexalate and other potassium binding agent. website. Retrieved September 22, 2022, from

  5. Sodium bicarbonate for hyperkalemia in the emergency department. Pharmacy Friday Pearls. (2022, February 11). Retrieved September 22, 2022, from