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Managing Hyperkalaemia: Cases & Treatment Protocols

Learn how to manage hyperkalaemia through real-life cases, essential tests, treatment options, and monitoring strategies. Understand the causes, ECG changes, and principles of treatment. Get insights on potassium regulation and potentially life-saving interventions.

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Managing Hyperkalaemia: Cases & Treatment Protocols

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  1. Death by Bananas The Management of Hyperkalaemia Dr. Kiaran Flanagan, Clinical Lead Acute Medicine UHCW June 2012

  2. Case 1 • Patient comes into ED referred by GP for high potassium of 6.7 • You see the notes in the SIFT tray • What do you do? ...

  3. How to manage • Pick up notes and PUT STICKER ON THE LIST • ABCDE • What are you likely to find? • What urgent investigation do you need to make a treatment decision? • What action would you take if • 1. Normal • 2. Abnormal

  4. What next? • History... • Examination... • Further tests • What are you looking for?

  5. What next... • Senior review? • Actions you should recommend... • Drugs • Monitoring • Admit/ Discharge • Further checks • Anticipated future actions • How will you make this happen?

  6. Case 2 • Patient on the ward • ATSP – unwell, vomiting • Day 2 of admission – post op R hemicolectomy • What do you do?

  7. What do you do? • ABCDE • Investigations? • Monitoring...

  8. Patient hyperkalaemic • What else do you look for? • What test needs to have been done? • What treatment do you need to give?

  9. Recheck K at 3 hours • Still high... • What next? • Treatment • Advice • Monitoring

  10. Recheck K at 6 hours • Still high... • What do you do? • Treatment • Monitoring • Ask for help • Who • What will you tell them and how? • What for

  11. Case 3 • Patient – Medical ALERT to Resus • Drowsy • High glucose • What do you do????

  12. What do you do? • ABCDE • Urgent tests • What is the diagnosis? • How do you manage?

  13. Case 4 • Cardiac Arrest Call • PEA • What do you think about?

  14. Hyperkalaemia in cardiac arrest • What do you give?

  15. Case 5 • Called to ward 1, pt unwell • Low BP, low glucose, high potassium • What do you do? • Assessment • Further tests? • Working diagnosis • Treatment?

  16. Causes of Hyperkalaemia • Decreased or impaired potassium excretion – renal failure, potassium-sparing diuretics, urinary obstruction, sickle cell disease, Addison disease, and systemic lupus erythematosus (SLE) • Additions of potassium into extracellular space - potassium supplements (eg, PO/IV potassium, salt substitutes), rhabdomyolysis, and hemolysis (eg, blood transfusions, burns, tumor lysis) • Transmembrane shifts (ie, shifting potassium from the intracellular to extracellular space) - acidosis and medication effects (eg, acute digitalis toxicity, beta-blockers, succinylcholine) • Factitious or pseudohyperkalemia - improper blood collection (eg, ischemic blood draw from venipuncture technique), laboratory error, leukocytosis, and thrombocytosis

  17. Causes • Ineffective elimination • Kidneys • Drugs • Endocrine • Excessive release from cells • Injury • Metabolic • Excessive intake • Lethal Injection • Pseudo

  18. ECG Changes

  19. How does it affect the heart? • Hyperkalemia results in: • Inhibition of atrial myocardial depolarization. • Slowing of heart rate. • Prolonging QRS duration; complexes may become bizarre. • Also known as atrial standstill. • Rhythm called sinoventricular rhythm. • The ECG is a poor substitute for serum potassium levels to determine the degree of abnormality

  20. ECG Changes • From reduction of P wave amplitude and prolongation of PR interval to absence of P waves altogether. • Increase of QRS duration. • Increase of QT duration. • Slowing of heart rate. • T waves become tall and spiked. • Decreased R wave amplitude

  21. ECG Changes

  22. 3 Principles of Treatment • Stabilise myocardium • Move it into cells • Increase elimination

  23. Dextrose - Insulin • How does it work? • How long for? • How do you give it? • What is the dose? • Other considerations...

  24. Calcium Gluconate • How does it work? • How long for? • How do you give it? • What is the dose? • Other considerations...

  25. Sodium Bicarbonate • How does it work? • How long for? • How do you give it? • What is the dose? • Other considerations...

  26. Calcium Resonium • Hmmm....

  27. More controversial • Salbutamol • Furosemide

  28. Protocols • If K > 6 mmol • Calcium Resonium • Unless – Rising fast/ patient septic then treat as below • If K > 6.5 – normal ECG • Dextrose Insulin • Calcium Resonium

  29. Protocols • If K > 6.5 – abnormal ECG or • If K > 7 • Calcium Gluconate • Dex Insulin • Salbutamol • Sodium Bicarbonate • RRT

  30. Important Bits... • POTENTIAL LIFE THREATENING EMERGENCY • TREAT IF INDICATED • TRUST BUT VERIFY • RECHECK • CARDIAC MONITORING • EXPERT HELP • PREVENTION

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