Hyperkalemia
If a triage ECG is not done for your dialysis patient, that 10 second strip of paper should be at the top of your priority list - Maninder Singh
image by: Rapid Sequence Interrogation - RSI Podcast
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Emergency Medicine Myth #3: Kayexelate in HyperK+, Useless? Harmful?
Hyperkalemia treatment is a core skill for emergency physicians and an area in which we excel. Give calcium to stabilize cardiac myocytes if there are ECG changes, insulin (plus dextrose), albuterol, and sodium bicarbonate to shift potassium into the cell, and then sodium polystyrene sulfonate (SPS; brand name Kayexalate) to eliminate the potassium from the body, right?
There are areas to debate within each of these steps, but I want to address the final one. SPS is a cation-exchange resin that was approved in 1958 as a treatment for hyperkalemia by helping to exchange sodium for potassium in the colon and excreting potassium from the body.
Resources
New Kid on The HyperK Block… Lokelma
First off, Lokelma is the brand name, and way more preferred over its generic name, Zirconium cyclosilicate, since it says right in the name what it does—it lowers your potassium. If you really want to show your age, you may see it sometimes referred to as ZS-9 when it was first being studied in the early 2010s. Per Kidney International Journal (who knew this existed): “Zirconium is a biologically inert trace element found widely in nature.” And according to other sources, you likely eat ~4 mg of zirconium daily in your normal diet.
A Brave New Kayexalate Free World
Although statistically a success, ZS-9 adds very little to the acute management of clinically relevant hyperkalemia. Even the high doses of ZS-9 reduced the potassium level on average by 0.73 mmol/L at 48-hours, nowhere near the efficacy that would allow us to comfortably hold dialysis overnight in the acutely hyperkalemic patient.
Emergency Management of Hyperkalemia
Little did I know that some of these therapies were based on theory alone while others were based on a few small poorly done studies. It turns out that some of these therapies may cause more harm than good, and that precisely when and how to give these therapies to optimize patient outcomes is still not really known.
Tiny Tip: C BIG K DROP (Management of Hyperkalemia with ECG changes)
A Cochrane review concluded that, when ECG changes due to hyperkalemia are present, IV calcium is effective in preventing deterioration. Thereafter, emergent therapies for lowering potassium levels are nebulized or inhaled salbutamol and/or IV insulin-and-glucose.
Back to Basics: Hyperkalemia Management
Remember, when you see a big K+, give "C BIG K"! (+ a few other options...)
ECG Changes of Hyperkalemia
Neither the ECG nor the plasma potassium alone are an adequate index of the severity of hyperkalemia, and providers should have a low threshold to initiate cardiac membrane stabilization in the setting of hyperkalemia and no ECG changes.
emDocs Cases: Updates in Management of Hyperkalemia
SPS or kayexalate is not recommended. New medications including patiromer and sodium zirconium cyclosilicate hold promise for GI excretion.
Hyperkalemia in the Emergency Department
Hyperkalemia remains a common diagnosis in critically ill patients presenting to the ED • Insulin/dextrose remains one of the most effective treatments to immediately shift K to a safe, intracellular space – but also has common side effects that can be amplified in patients with renal dysfunction.
Hyperkalemia
If a triage ECG is not done for your dialysis patient, that 10 second strip of paper should be at the top of your priority list.
Hyperkalemia Management: Preventing Hypoglycemia From Insulin
Though insulin certainly lowers plasma potassium concentrations, we often underestimate the hypoglycemic potential of a 10 unit IV insulin dose in this setting. The purpose of this post is to highlight the need for proper supplemental glucose and blood glucose monitoring when treating hyperkalemia with insulin.
Hyperkalemia, “Answers”
Hyperkalemia is one of the most lethal and treatable metabolic disturbances faced by emergency physicians. Therefore, its rapid recognition and treatment is paramount to the survival of the critically ill patient. Oftentimes, the EKG is utilized to assist in its early identification at the bedside, before lab results return.
Management of Hyperkalemia in the ED
The goals of treatment are stabilizing the resting membrane potential, shifting potassium intracellularly, and eliminating potassium from the body. A helpful pneumonic is "C B2IG K Drop."
Management of life-threatening hyperkalemia
3 amps (30ml) of calcium gluconate is equivalent to 1 amp (10ml) of calcium chloride.
The Beef with Bicarb! The Use of Sodium Bicarbonate in Hyperkalemia with Jimmy Pruitt
There’s controversy as to whether hypertonic sodium bicarbonate is beneficial for the acute treatment of hyperkalemia due to modifications in the mechanism of action.
Emergency Medicine Myth #3: Kayexelate in HyperK+, Useless? Harmful?
Save your patient, yourself, and your nurses from dealing with the unpleasant after-effects of SPS (i.e., diarrhea) by avoiding this ineffective and potentially dangerous medication.
Core EM
Hyperkalemia can present with a number of “non-classic” EKG findings including AV blocks and sinus bradycardia (Mattu 2000).
EMCrit
If bicarbonate is low, resuscitate with isotonic bicarbonate (D5W with 150 mEq/L sodium bicarbonate, typically three 50-mEq amps of bicarb in a liter of D5W).
Life in the Fastlane
Cardiac arrest... don’t stop until K+ normalised.
SAEM
Obtain an ECG on patients with chronic kidney disease who present with generalized fatigue and weakness to quickly screen for hyperkalemia. Patients with no reason for hyperkalemia found incidentally should have the potassium level repeated to make sure hemolysis is not present. Calcium salts only stabilize the cardiac membrane and do nothing to lower the potassium level and further treatment is required to lower the potassium level.
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