The 3-Step Approach to Acute Hyperkalemia
1. Stabilize: the Heart (If ECG changes) → Calcium
2. Shift: K+ Into Cells → Insulin + Glucose, Albuterol, Bicarb (if acidotic)
3. Send-it: Remove K+ From Body → Diuretics (if making urine), Kayexalate (if GI motility intact), Dialysis (if severe/refractory)
I – IV Fluids
C – Calcium
B – Beta-2 Agonists
B – Bicarbonate
I – Insulin & Glucose
K – Kayexalate (Sodium Polystyrene Sulfonate)
D – Diuretics
D – Dialysis
1. First Step: Assess ECG & Risk of Arrhythmia
• Peaked T waves, QRS widening, sine wave = Give Calcium ASAP
• Calcium doesn’t lower K+, but it prevents cardiac arrest.
2. Temporary vs. Definitive Treatments
• Shifting K+ into cells (Beta-agonists, Bicarb, Insulin) buys time.
• Excreting K+ (Diuretics, Dialysis, Kayexalate) removes K+.
3. Timing of Interventions:
• Calcium: Immediate (stabilizes heart).
• Insulin/Albuterol/Bicarb: 15–30 min (shifts K+).
• Diuretics/Kayexalate: 1–6 hours (removes K+).
• Dialysis: Immediate, definitive.
4. Common Pitfalls & Pro Tips
• Insulin can cause hypoglycemia – recheck glucose in 30 minutes.
• Albuterol requires high doses – typical 2.5 mg nebs won’t cut it.
• Bicarb only works if acidotic – don’t rely on it in normotensive patients.
• Kayexalate is slow & controversial – consider patiromer or zirconium cyclosilicate instead in chronic cases.
• If oliguric or ESRD → Straight to dialysis.
