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Although hyperkalemia is defined as a serum potassium concentration _5 mEq/L, it is moderate (6 to 7 mEq/L) and severe (_7 mEq/L) hyperkalemia that are life-threatening and require immediate therapy. Hyperkalemia is most commonly seen in patients with end-stage renal disease. Other causes are listed in the Table. Many medications can contribute to the development of hyperkalemia. Identification of potential causes of hyperkalemia will contribute to rapid identification and treatment.1–3 Signs and symptoms of hyperkalemia include weakness, ascending paralysis, and respiratory failure. A variety of electrocardiographic (ECG) changes suggest hyperkalemia. Early findings include peaked T waves (tenting). As the serum potassium rises further, flattened P waves, prolonged PR interval (first-degree heart block), widened QRS complex, deepened S waves, and merging of S and T waves can be seen. If hyperkalemia is left untreated, a sine-wave pattern, idioventricular rhythms, and asystolic cardiac arrest may develop. Treatment of Hyperkalemia The treatment of hyperkalemia is determined by its severity and the patient’s clinical condition. Stop sources of exogenous potassium administration (eg, consider supplements and maintenance IV fluids) and evaluate drugs that can increase serum potassium (eg, potassium-sparing diuretics, angiotensinconverting enzyme [ACE] inhibitors, nonsteroidal antiantiinflammatory agents). Additional treatment is based on the severity of the hyperkalemia and its clinical consequences. The following sequences list the treatments for hyperkalemia in order of priority. For mild elevation (5 to 6 mEq/L), remove potassium from the body with 1. Diuretics: furosemide 40 to 80 mg IV 2. Resins: Kayexalate 15 to 30 g in 50 to 100 mL of 20% sorbitol either orally or by retention enema For moderate elevation (6 to 7 mEq/L), shift potassium intracellularly with 1. Glucose plus insulin: mix 25 g (50 mL of D50) glucose and 10 U regular insulin and give IV over 15 to 30 minutes 2. Sodium bicarbonate: 50 mEq IV over 5 minutes (sodium bicarbonate alone is less effective than glucose plus insulin or nebulized albuterol, particularly for treatment of patients with renal failure; it is best used in conjunction with these medications4,5) 3. Nebulized albuterol: 10 to 20 mg nebulized over 15 minutes For severe elevation (_7 mEq/L with toxic ECG changes), you need to shift potassium into the cells and eliminate potassium from the body. Therapies that shift potassium will act rapidly but they are temporary; if the serum potassium rebounds you may need to repeat those therapies. In order of priority, treatment includes the following:
(Circulation. 2005;112:IV-121-IV-125.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166563
TABLE. Common Causes of Hyperkalemia
Endogenous Causes ● Chronic renal failure ● Metabolic acidosis (eg, diabetic ketoacidosis) ● Pseudohypoaldosteronism type II (also known as Gordon’s syndrome; familial hyperkalemia and hypertension) ● Chemotherapy causing tumor lysis ● Muscle breakdown (rhabdomyolysis) ● Renal tubular acidosis
heparin therapy (especially in patients with other risk factors). severe hyperglycemia. amphotericin B). Dialysis Hypokalemia Hypokalemia is defined as a serum potassium level _3. but the tip of the catheter used for the infusion should . The most common causes of low serum potassium are gastrointestinal loss (diarrhea. sodium penicillin. paralysis. ACE inhibitors. Nebulized albuterol: 10 to 20 mg nebulized over 15 minutes5–7 ● Promote potassium excretion: 5. Treatment of Hypokalemia The treatment of hypokalemia consists of minimizing further potassium loss and providing potassium replacement. succinylcholine.5 mEq/L). A more concentrated solution of potassium may be infused if a central line is used. Administration of potassium may be empirical in emergent conditions. high white blood cell count. particularly ventricular arrhythmias. Hypokalemia can produce ECG changes such as U waves. _-blockers ● Blood administration (particularly with large transfusions of older “bank” blood) ● Diet (rarely the sole cause). nonsteroidal anti-inflammatory drugs. respiratory difficulty. Diuresis: furosemide 40 to 80 mg IV 6. the maximum amount of IV potassium replacement should be 10 to 20 mEq/h with continuous ECG monitoring during infusion. intracellular shift (alkalosis or a rise in pH). Gradual correction of hypokalemia is preferable to rapid correction unless the patient is clinically unstable. T-wave flattening.● Hemolysis ● Hypoaldosteronism (Addison’s disease. hyporeninemia) ● Hyperkalemic periodic paralysis Exogenous Causes ● Medications: K_-sparing diuretics. fatigue. penicillin derivatives. Calcium chloride (10%): 500 to 1000 mg (5 to 10 mL) IV over 2 to 5 minutes to reduce the effects of potassium at the myocardial cell membrane (lowers risk of ventricular fibrillation [VF]) 2. When indicated. particularly if the patient has coronary artery disease or is taking a digitalis derivative. Kayexalate enema: 15 to 50 g plus sorbitol PO or per rectum 7. Glucose plus insulin: mix 25 g (50 mL of D50) glucose and 10 U regular insulin and give IV over 15 to 30 minutes 4. more severe hypokalemia will alter cardiac tissue excitability and conduction. IV administration of potassium is indicated when arrhythmias are present or hypokalemia is severe (potassium level of _2. potassiumdepleting diuretics. potassium supplements. paralytic ileus. The myocardium is extremely sensitive to the effects of hypokalemia. tumor lysis syndrome) ● Shift potassium into cells: 1. and malnutrition. renal loss (hyperaldosteronism. laxatives). high platelets. Sodium bicarbonate: 50 mEq IV over 5 minutes (may be less effective for patients with end-stage renal disease) 3. and leg cramps. Symptoms of mild hypokalemia are weakness. The major consequences of severe hypokalemia result from its effects on nerves and muscles (including the heart). constipation. salt substitutes ● Pseudohyperkalemia (due to blood sampling or hemolysis. and arrhythmias (especially if the patient is taking digoxin). Pulseless electrical activity or asystole may develop. carbenicillin.5 mEq/L.
therapy is determined by the presence or absence of a perfusing rhythm. repeat once if needed. General Care for All Victims of Hypothermia When the victim is extremely cold but has maintained a perfusing rhythm. These patients are prone to develop ventricular fibrillation (VF). Document in thepatient’s chart that rapid infusion is intentional in response to life-threatening hypokalemia. warm water packs) but no invasive devices. consider extracorporeal membrane oxygenation ● Patients in cardiac arrest will require CPR with some modifications of conventional BLS and ACLS care and will require active internal rewarming –Moderate (30°C to 34°C [86°F to 93. These include the following: ● Prevent additional evaporative heat loss by removing wet garments and insulating the victim from further environmental exposures.7. but perform them gently while closely monitoring cardiac rhythm. establish IV access. attempt defibrillation once. Give an initial infusion of 10 mEq IV over 5 minutes. Active external rewarming uses heating methods or devices (radiant heat. such as intubation and insertion of vascular catheters.2°F]): active external rewarming –Severe (_30°C [86°F]): active internal rewarming. active internal rewarming techniques (invasive) are needed. and warmed infusion) should be considered (Class IIb). ● Do not delay urgent procedures.not extend into the right atrium. malignant ventricular arrhythmias are present). With or without return of spontaneous .8 –For patients with a core body temperature _30°C (86°F) and cardiac arrest. This form of rewarming will not be adequate for a patient with cardiopulmonary arrest or severe hypothermia. rapid replacement of potassium is required.2°F) may be passively rewarmed with warmed blankets and a warm environment.2°F]) and a perfusing rhythm and no preceding cardiac arrest.2°F]): start CPR. even those with severe hypothermia. provide active internal rewarming –Severe (_30°C [86°F]): start CPR. provide active internal rewarming –Patients with a core temperature of _34°C (_93. give IV medications spaced at longer intervals. forced hot air. attempt defibrillation. the rescuer should focus on interventions that prevent further heat loss and begin to rewarm the victim. withhold medications until temperature _30°C (86°F). For patients with moderate to severe hypothermia. But recent studies have indicated that forced air rewarming (one study used warmed IV fluids and forced air rewarming) is effective in some patients. Some researchers believe that active external rewarming contributes to “afterdrop” (continued drop in core temperature when cold blood from the periphery is mobilized).2°F]): passive rewarming –Moderate (30°C to 34°C [86°F to 93. warmed IV fluids. active external warming (with heating blankets. If cardiac arrest from hypokalemia is imminent (ie. We provide an overview of therapy here and give more details below. forced air.6 –For patients with moderate hypothermia (30°C to 34°C [86°F to 93. Management of the patient with moderate to severe hypothermia is as follows: ● Hypothermia with a perfusing rhythm –Mild (_34°C [_93. Use of these methods requires careful monitoring for hemodynamic changes and tissue injury from external heating devices.
6°F) before repeating the defibrillation attempt.112:IV-136-IV-138.1161/CIRCULATIONAHA.10 If the victim is not breathing. 2005.166566 IV-136 of defibrillation attempts that should be made have not been established. Beyond these critical initial steps. If there is any doubt about whether a pulse is present. Automated external defibrillators (AEDs) may be used for these patients. and the rescuer should focus on continuing CPR and rewarming the patient to a range of 30°C to 32°C (86°F to 89.12. Many providers do not have the time or equipment to assess core body temperature or to institute aggressive rewarming techniques. start rescue breathing immediately.9 If the hypothermic victim is in cardiac arrest. If core temperature is _30°C (86°F).4.circulation. ACLS management of cardiac arrest due to hypothermia . it should be treated with 1 shock then immediately followed by resumption of CPR. But if ventricular tachycardia (VT) or VF is present.11 To prevent further core heat loss. If possible.4. cardiopulmonary bypass. If the victim is pulseless with no detectable signs of circulation. pulseless cardiac arrest. begin compressions. although these methods should be initiated when available. pulse and respiratory rates may be slow or difficult to detect.org DOI: 10.circulationaha. Cardioversion. Insofar as possible this should be done while providing initial BLS therapies. these patients may benefit from prolonged CPR and internal warming (peritoneal lavage. extracorporeal circulation. humidified oxygen. When the victim is hypothermic. start chest compressions immediately. remove wet garments and protect the victim from further environmental exposure. endotracheal intubation is appropriate. The temperature at which defibrillation should first be attempted in the severely hypothermic patient and the number (Circulation. the general approach to BLS management should still target airway. This special supplement to Circulation is freely available at http://www. etc). Modifications of BLS for Hypothermia If the hypothermic victim has not yet developed cardiac arrest. and circulation but with some modifications in approach. Defibrillation. and Pacing”). successful conversion to normal sinus rhythm may not be possible until rewarming is accomplished. further defibrillation attempts should be deferred. focus attention on warming the patient with available methods. If the patient does not respond to 1 shock.) © 2005 American Heart Association.13 Modifications to ACLS for Hypothermia For unresponsive patients or those in arrest. For these reasons the BLS healthcare provider should assess breathing and later assess the pulse for a period of 30 to 45 seconds to confirm respiratory arrest. esophageal rewarming tubes. as outlined elsewhere in these guidelines for VF/VT (see Part 5: “Electrical Therapies: Automated External Defibrillators. Handle the victim gently for all procedures. and it can isolate the airway to reduce the likelihood of aspiration.105. defibrillation should be attempted. Intubation serves 2 purposes in the management of hypothermia: it enables provision of effective ventilation with warm. the treatment of severe hypothermia (temperature _30°C [86°F]) in the field remains controversial. breathing. physical manipulations have been reported to precipitate VF. administer warmed (42°C to 46°C [108°F to 115°F]) humidified oxygen during bag-mask ventilation.9. or bradycardia that is profound enough to require CPR. If VF is detected.
14.focuses on more aggressive active core rewarming techniques as the primary therapeutic modality. In-hospital treatment of severely hypothermic (core temperature _30°C [86°F]) victims in cardiac arrest should be directed at rapid core rewarming. extracorporeal blood warming with partial bypass. the clinician must look for and treat these underlying conditions while simultaneously treating the hypothermia. defer subsequent defibrillation attempts or additional boluses of medication until the core temperature rises above 30°C (86°F).18 If drowning preceded hypothermia. alcohol use. a defibrillation attempt is appropriate if VF/VT is present. There is concern that in the severely hypothermic victim.9 In addition.15 and cardiopulmonary bypass. The hypothermic heart may be unresponsive to cardiovascular drugs.17. For these reasons IV drugs are often withheld if the victim’s core body temperature is _30°C (86°F). patients who have been hypothermic for _45 to 60 minutes are likely to require volume administration because the vascular space expands with vasodilation. and cardiac pacing is usually not indicated. pleural lavage with warm saline through chest tubes. If the core body temperature is _30°C. 16 During rewarming. Techniques for in-hospital controlled rewarming include administration of warmed. cardioactive medications can accumulate to toxic levels in the peripheral circulation if given repeatedly. humidified oxygen (42°C to 46°C [108°F to 115°F]). Routine administration of steroids. As noted previously. . drug metabolism is reduced. If the patient fails to respond to the initial defibrillation attempt or initial drug therapy. drug overdose.9 Sinus bradycardia may be physiologic in severe hypothermia (ie. peritoneal lavage with warmed fluids. IV medications may be administered but with increased intervals between doses. warmed IV fluids (normal saline) at 43°C (109°F). successful resuscitation is unlikely. appropriate to maintain sufficient oxygen delivery when hypothermia is present).12. and antibiotics has not been documented to increase survival rates or decrease postresuscitation damage. or trauma). and defibrillation. pacemaker stimulation. Because severe hypothermia is frequently preceded by other disorders (eg.9. barbiturates. 4.
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