Hyperkalemia: STABILIZE, SHIFT, SEND-IT (I C BIG K DROP)

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 FluidsC – CalciumB – Beta-2 AgonistsB – BicarbonateI – Insulin & GlucoseK – Kayexalate (Sodium Polystyrene Sulfonate)D – DiureticsD – Dialysis1. 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.