Hyperkalaemia ⚡️
UK emergency management of hyperkalaemia per Gloucestershire Hospitals guidance: ECG thresholds, calcium gluconate, insulin-dextrose, salbutamol, and sodium zirconium cyclosilicate.
📍 Guidance source
- This topic follows Gloucestershire Hospitals NHS Foundation Trust: Acute management of hyperkalaemia (approved March 2023).
- Confirm your local Trust hyperkalaemia pathway. Binders, calcium timing, and monitoring schedules can differ between hospitals.
🧠 Definition & initial steps
- Plasma K⁺ > 5.5 mmol/L. Assess with ABCDE; consider rate of rise (e.g. rhabdomyolysis, oliguric renal failure).
- 12-lead ECG and cardiac rhythm monitoring if serum K⁺ ≥ 6.0 mmol/L.
- Exclude pseudohyperkalaemia (repeat VBG K⁺ if haemolysis suspected, or send a lithium heparin sample).
- Cardiac arrest or life-threatening arrhythmia with suspected hyperkalaemia: follow ALS algorithms and treat as severe hyperkalaemia with urgent IV calcium.
📊 Severity bands (first 15 minutes)
- K⁺ 5.5–5.9: no acute treatment needed. Consider and treat the cause.
- K⁺ 6.0–6.4 (moderate): give sodium zirconium cyclosilicate 10 g PO if able to tolerate oral medication. Does not delay assessment or other treatments when indicated.
- K⁺ > 6.5 (severe): protect the heart if ECG changes or K⁺ > 6.5, then shift and remove potassium as below.
🩺 ECG changes to treat as urgent
- Peaked T waves, broad QRS, bradycardia, flat or absent P waves, sine wave, VT.
- Also watch for prolonged PR interval. Repeat 12-lead ECG after calcium to confirm resolution.
- Do not delay emergency treatment while awaiting transfer to a monitored bay.
💊 Protect the heart (calcium)
- If ECG changes or K⁺ > 6.5: calcium gluconate 10% 30 ml IV (≈ 6.8 mmol) via large peripheral vein over 5 minutes with continuous cardiac monitoring.
- If a large vein is not available, give over 10 minutes and watch for extravasation. Give over 30 minutes if the patient is taking digoxin.
- Repeat ECG. Consider a further dose after 5 minutes if ECG changes persist; can be repeated every 5 minutes. Effect is transient (30–60 minutes).
- Do not mix with other drugs. Do not give sodium bicarbonate through the same access (insoluble calcium salts).
💉 Shift potassium into cells (next 30–60 minutes)
- Insulin–glucose: 10 units Actrapid in 25 g glucose IV over 15 minutes (50 ml 50% dextrose, or 125 ml 20%, or 250 ml 10%).
- If pre-treatment blood glucose is < 7.0 mmol/L: start 10% dextrose at 50 ml/h for 5 hours after the initial infusion.
- Do not give dextrose in DKA; give insulin only if capillary glucose is ≥ 20 mmol/L.
- Nebulised salbutamol 10–20 mg (use 10 mg if history of ischaemic heart disease or severe tachycardia). Can be used as first-line while IV access for insulin–glucose is being established. May add a further 0.5–1 mmol/L fall with insulin–glucose; less effective on beta-blockers or digoxin.
- Intravenous sodium bicarbonate: only for severe metabolic acidosis when recommended by an intensivist or nephrologist. Oral sodium bicarbonate may be considered if acidosis is present.
🚽 Remove potassium & prevent recurrence
- Sodium zirconium cyclosilicate (Lokelma) 10 g PO TDS for up to 72 hours for acute treatment (suspension in ~45 ml water; drink while cloudy).
- Separate by at least 2 hours from oral drugs with pH-dependent bioavailability (e.g. some azoles, antiretrovirals, TKIs).
- Stop offending medicines where appropriate: potassium supplements, salt substitutes, ACE inhibitors, ARBs, NSAIDs, spironolactone, eplerenone, amiloride, trimethoprim, digoxin.
- Low potassium diet once urgent treatment is underway. Refer CKD stage 4–5 to a dietitian before discharge.
- Haemodialysis or haemofiltration for severe resistant hyperkalaemia or ongoing tissue damage: involve Critical Care or the on-call renal consultant early.
📈 Monitoring
- Aim for serum K⁺ < 6.0 mmol/L within 2 hours.
- Measure potassium at 1, 2, 4, and 6 hours after initial treatment (detect fall and rebound); check again at 24 hours.
- Glucose target 4–7 mmol/L. Monitor capillary glucose at 0, 15, and 30 minutes, then hourly up to 6 hours (delayed hypoglycaemia is common).
- If K⁺ remains > 6.5 after treatment: repeat previous treatments and seek expert help (cardiology or renal).
⚠️ When to escalate
- K⁺ > 6.5 after treatment, persistent ECG changes, oliguric or anuric AKI, ESRD or dialysis patients, or ongoing tissue necrosis.
- Seek cardiology or renal advice early for resistant or life-threatening cases.
Hyperkalaemia Management Assistant (UK)
Gloucestershire Hospitals inpatient protocol (March 2023). Confirm your Trust pathway.
Clinical Factors
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:04 ATRP re: hyperkalaemia Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [CKD / diabetes / medications affecting K⁺] 🧾 Hx: • Symptoms: [weakness / palpitations / chest discomfort] • Duration: [acute / chronic] • Medications: [ACEi / ARB / spironolactone / others] • Diet / supplements 🩺 Exam: • HR: __ BP: __ RR: __ Temp: __ SpO₂: __ • Signs of arrhythmia or volume overload • Neuro: [alert / confused] 📋 Impression: Likely cause: [renal impairment / medications / acidosis] 📌 Plan: • Venous K⁺ and ECG • Management and review cadence as per management plan / local hyperkalaemia protocol 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer