CCS Case: Hyperkalemia with ECG Changes

Case: Hyperkalemia with ECG Changes

Clinical Setup

• Presentation: 64-year-old male with CKD on lisinopril and spironolactone, weakness, palpitations, K+ 6.8 mEq/L, ECG shows peaked T waves and widened QRS.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Continuous cardiac monitoring, pulse oximetry, BP q15min.
   • IV access, Normal saline 0.9% IV (avoid potassium-containing fluids).
   • Stop all potassium-raising drugs: ACE-I, spironolactone, TMP, NSAIDs.
2. Focused Exam (Minute 1–2):
   • Neuro exam (ascending weakness, decreased reflexes), cardiac exam, volume status.
3. Diagnostics (Minute 2–5):
   • ECG stat (peaked T, PR prolongation, QRS widening).
   • Repeat BMP stat (confirm K+; rule out hemolysis/pseudohyperkalemia), CBC, ABG/VBG, serum osmolality if indicated.
   • Review medication list and recent labs (creatinine trend, BUN).
4. Therapeutics (Minute 5–15):
   • Stabilize cardiac membrane FIRST: Calcium gluconate or calcium chloride IV stat (does not lower K+).
   • Shift K+ intracellularly: Regular insulin IV + glucose (e.g., 10 units IV with dextrose), plus nebulized albuterol.
   • Remove K+ from body: loop diuretic if volume overloaded with urine output; sodium zirconium cyclosilicate or patiromer per protocol; nephrology consult for emergent dialysis if refractory, anuric, or severe acidosis.
   • Correct metabolic acidosis with bicarbonate if pH < 7.2 and severe.
   • Recheck K+ and ECG every 1–2 hours; advance clock in short increments.
5. Disposition (Minute 15–20):
   • Admit to ICU/telemetry until K+ normalized and ECG resolved.
   • Hold nephrotoxins; adjust home meds (discontinue K+-sparing agents).
6. Final 2 Minutes:
   • Counsel on low-potassium diet, medication review, CKD follow-up.
   • Schedule nephrology and primary care follow-up; arrange repeat BMP within days.