Synopsis
Confirm and risk-stratify raised potassium, stabilise cardiac membranes, shift potassium safely and secure definitive removal with rebound surveillance.
- UKKA defines hyperkalaemia from 5.5 mmol/L and recommends an urgent 12-lead ECG for every hospitalised adult with potassium at least 6.0 mmol/L.
- Use continuous three-lead monitoring at 6.5 mmol/L or above, with any hyperkalaemic ECG feature, or at 6.0–6.4 mmol/L when the patient is unwell or a rapid rise is expected.
- Repeat a potentially haemolysed or surprising sample promptly, but never delay treatment when the ECG, potassium and clinical context indicate genuine severe toxicity.
- Intravenous calcium stabilises the myocardium within minutes but does not lower serum potassium; potassium-shifting and removal treatment must proceed alongside it.
- UKKA’s standard insulin–glucose regimen is 10 units soluble insulin with 25 g glucose, with extra glucose infusion when pretreatment glucose is below 7 mmol/L and scheduled monitoring for six hours.
- Nebulised salbutamol is an adjunct, not monotherapy for severe disease, and response may be limited in patients taking non-selective beta-blockers.
- Shift therapies wear off: repeat potassium at 1, 2, 4, 6 and 24 hours under UKKA guidance and arrange definitive gastrointestinal or dialysis removal when indicated.
- After stabilisation, preserve beneficial renin–angiotensin or heart-failure therapy where possible through cause correction, dietary review and specialist potassium binders rather than automatic permanent withdrawal.
Key red flags
Peaked T waves, prolonged PR, flattened or absent P waves, widening QRS, bradycardia, sine wave or ventricular arrhythmia demands immediate calcium treatment.
Paraesthesia, ascending weakness, flaccid paralysis or ventilatory compromise can accompany severe hyperkalaemia and should not be mistaken for a primary neurological disorder.
Oliguria, acute kidney injury, missed dialysis or access dysfunction predicts impaired removal and lowers the threshold for urgent renal replacement planning.
Crush injury, prolonged seizure, burns, rhabdomyolysis, tumour lysis or haemolysis can release potassium continuously and cause rapid rebound after temporary shifting.
Investigation priorities
Detect cardiac membrane toxicity and determine the immediate need for intravenous calcium.
Management branches
A laboratory or point-of-care result shows raised potassium or the ECG suggests hyperkalaemia.
- Use ABCDE, repeat potassium appropriately, obtain an urgent 12-lead ECG at 6.0 mmol/L or above and establish continuous monitoring for UKKA high-risk categories.
- Review renal output, acid–base state, glucose, medicines, cell injury and dialysis history while stopping exogenous potassium and avoidable causal agents.
- If severe potassium or toxic ECG change is present, activate the hospital algorithm immediately and call senior, renal and critical-care teams before confirmation delays treatment.