START: Hyperkalemia Detected
Serum K+ >5.5 mEq/L (or elevated above normal)
All Pathways
Emergency MedicineEmergency
Hyperkalemia Emergency Management (AHA 2025)
Hyperkalemia Emergency Management (AHA 2025): START: Hyperkalemia Detected → Confirm and Assess → ECG Changes Present? → ECG Changes = EMERGENCY → STEP ...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Confirm and Assess
Rule out pseudohyperkalemia, assess urgency
- Check for hemolysis, difficult draw, high WBC/platelets
- Repeat K+ if unexpected result
- Get 12-lead ECG immediately
- Review medications (ACE-I, ARB, K-sparing diuretics, NSAIDs)
03Decision ECG Changes Present?
Evaluate for cardiac toxicity
- EARLY (K+ 5.5-6.5): Peaked/tall T waves
- MODERATE (K+ 6.5-7.5): Prolonged PR, flattened P waves
- SEVERE (K+ >7.5): Wide QRS, sine wave pattern, VF risk
- Note: ECG changes don't always correlate with K+ level
04Warning ECG Changes = EMERGENCY
Immediate cardiac membrane stabilization
05Action STEP 1: Calcium (Cardiac Protection)
Immediate IV calcium - stabilizes myocardium
- Calcium gluconate 10% 10-20 mL IV over 2-3 min
- OR Calcium chloride 10% 5-10 mL IV (central line preferred)
- Onset: 1-3 minutes
- Duration: 30-60 minutes
- May repeat in 5-10 min if ECG not improved
- ⚠️ Caution in digoxin toxicity (give slower, 20-30 min)
06Action STEP 2: Shift K+ Into Cells
Temporarily lowers serum K+
- INSULIN + GLUCOSE:
- - Regular insulin 10 units IV
- - PLUS D50W 25-50 mL IV (if glucose <250)
- - Onset: 15-30 min, Duration: 4-6 hr
- - Monitor glucose q1h x 4-6 hrs
- BETA-AGONIST (Albuterol):
- - 10-20 mg nebulized over 10 min
- - Onset: 30 min, Duration: 2-4 hr
- - Additive to insulin
- SODIUM BICARBONATE:
- - 50-100 mEq IV if acidotic (pH <7.2)
- - Less effective if no acidosis
07Decision Dialysis Needed?
Consider urgency and indication
- DIALYSIS INDICATIONS:
- - Refractory to medical therapy
- - Oliguric/anuric renal failure
- - Severely elevated K+ (>7) with symptoms
- - ECG changes persist despite treatment
08Warning Emergent Dialysis
Contact nephrology immediately
- Hemodialysis preferred (fastest K+ removal)
- CRRT if hemodynamically unstable
- Temporary dialysis catheter if no access
- Continue medical therapy while arranging
09Action Monitoring
Close follow-up required
- Repeat K+ in 1-2 hours after treatment
- Continuous cardiac monitoring if ECG changes
- Monitor glucose q1h x 6hr after insulin
- Re-treat if K+ rises or ECG changes recur
10Action Address Underlying Cause
Prevent recurrence
- Stop offending medications
- Treat AKI/CKD
- Correct acidosis
- Address diet (high K+ foods)
- Nephrology follow-up if needed
11Outcome K+ Normalized
Continue monitoring and prevention
- Target K+ <5.5 mEq/L
- Maintain dietary potassium restriction if needed
- Consider chronic potassium binder if recurrent
- Medication review and adjustment
12Action STEP 3: Eliminate K+ From Body
Definitive removal
- LOOP DIURETICS (if adequate renal function):
- - Furosemide 40-80 mg IV
- POTASSIUM BINDERS:
- - Patiromer (Veltassa) 8.4g PO - onset 7 hrs
- - Sodium zirconium cyclosilicate (Lokelma) 10g PO - onset 1 hr
- - SPS/Kayexalate 15-30g PO (avoid in bowel issues)
- DIALYSIS (definitive):
- - Indicated for severe/refractory hyperkalemia
- - ESRD or AKI with oliguria
- - Removes 25-50 mEq K+ per hour
- Path rejoins step 09Shared downstream outcome
13Decision Potassium Level
Severity without ECG changes
14Action K+ 5.5-6.4 (Moderate)
Lower acuity but still treat
- Remove K+ from IV fluids and diet
- Stop offending medications
- May use potassium binders if stable
- Consider shift therapy if rising
- Path rejoins step 12Shared downstream outcome
15Action K+ ≥6.5 (Severe)
Urgent treatment even without ECG changes
- Consider calcium for protection
- Proceed to shift therapy
- Prepare for dialysis if renal failure
- Path rejoins step 06Shared downstream outcome
Guideline Source
AHA 2025 Guidelines Part 10: Special Circumstances - Hyperkalemia
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address underlying cause treatment in detail
- Dialysis availability varies by institution
- Calcium dosing may vary in digoxin toxicity
- Insulin/dextrose requires glucose monitoring
- Potassium binders take hours to work
Applicable Regions
USEUGlobal
EU: ERC guidelines similar approach
US: AHA 2025 is current standard
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Hyperkalemia Emergency Management (AHA 2025)?
The Hyperkalemia Emergency Management (AHA 2025) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on AHA 2025 Guidelines Part 10: Special Circumstances - Hyperkalemia.
What guideline is the Hyperkalemia Emergency Management (AHA 2025) based on?
This algorithm is based on AHA 2025 Guidelines Part 10: Special Circumstances - Hyperkalemia (DOI: Part 10 Special Circumstances).
What are the limitations of the Hyperkalemia Emergency Management (AHA 2025)?
Known limitations include: Does not address underlying cause treatment in detail; Dialysis availability varies by institution; Calcium dosing may vary in digoxin toxicity; Insulin/dextrose requires glucose monitoring; Potassium binders take hours to work. Individual patient factors may require deviation from these recommendations.
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