Makindo Medical Notes.com

The hyperkalaemia at being 7.5 mml/L is in the danger zone and needs immediate treatment. It is very credible as there is obvious AKI and also she is on spironolactone.

• Start Telemetry and ensure defibrillator close by
• Get a 12 lead ECG done and at the same time
• Administer 10 mls of 10% IV Calcium Gluconate. Give slowly

• Mild (K 5.5-5.9 mmol/L)
• Moderate (K 6.0-6.4 mmol/L)
• Severe (K >6.5 mmol/L) or if ECG changes or symptoms.

Start Emergency treatment when K >6.5 mmol/L or K >6.0 mmol/L and there are ECG changes. Give Calcium Gluconate and prepare Insulin and Dextrose

ECG signs of Hyperkalaemia

• Peaked tented T waves
• Absent P waves
• Broad QRS
• Sine waves
• Bradycardia
• Agonal rhythm
• Cardiac arrest with VT/VF.

• If dry or euvolaemic consider IV fluids
• Give a further 10 mls of Calcium Gluconate again slow IV and ask the nurse to prepare
• 10 U of Short acting Insulin (Actrapid) with 100 ml of 25 % Dextrose or 50 ml of 50% dextrose
• Also consider nebulised salbutamol 10mg to 20mg, astolerated. Give 10mg salbutamol if elderly, arrhythmias, ischaemic heartdisease or tachycardia

It would be reasonable to

• Ensure that you stop Spironolactone. It may be reasonable to restart the ACEI after a few days if K remains normal with ongoing monitoring.
• Start Calcium Resonium 15 g 6 hrly to help remove potassium. Other similar agents are available now. This has little effect acutely and takes days to have an effect.
• Low potassium diet is wise. Ask for dietetic help if needed.
• Continue to monitor U&E for several days until safely down.
• The hope is that stopping spironolactone will help.
• Consider NaHCO₃ if HCO₃ < 15 mmol/L

Talk to renal about the need for haemodialysis to help remove K

• Follow the usual ACLS algorithm for shockable and non-shockable rhythms
• If suspicious one would conform hyperkalaemia using a blood gas analyser if available but here we have a high suspicion here. An ABG is sent and the K is 8.5
• Protect the heart: give further 10 mL calcium chloride 10% IV by rapid bolus injection. Consider repeating dose if cardiac arrest is refractory or prolonged.
• Consider further 10 units soluble insulin and 25 g glucose IV by rapid injection. Monitor blood glucose. Administer 10% glucose infusion guided by blood glucose to avoid hypoglycaemia.
• Shift potassium into cells: Give 50 mmol sodium bicarbonate (50 mL 8.4% solution) IV by rapid injection.
• Remove potassium from the body: Consider dialysis for refractory hyperkalaemic cardiac arrest.
• Consider the use of a mechanical chest compression device if prolonged CPR is needed.
• Consider ECLS or ECPR for patients who are peri-arrest or in cardiac arrest as rescue therapy in those settings where it is feasible.