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Emergency Medical Minute


Feb 28, 2022

Contributor: Nick Tsipis, MD

Educational Pearls:

  • Acute hyperkalemia is characterized as serum K of 5.4 or higher in non-hemolyzed samples
  • Hyperkalemia is commonly associated with end stage renal disease, acute kidney injury or acute renal failure
  • Cardiac dysrhythmias are the primary concern with hyperkalemia, common EKG changes (and approximate serum levels) can include:
    • Peaked T waves that start to show at serum K of 6 
    • Second sign is lengthening of PR and QRS intervals due to extended repolarization
    • Severe hyperkalemia manifests as a sine wave around serum of 8-9
  • Three approaches to treat hyperkalemia:
    • Stabilize cardiac membrane with calcium
    • Shift potassium  back into the cell, insulin and albuterol are common agents used.
    • Potassium binding for excretion 
  • Cochrane review showed no significant effects of Kayexalate on serum K in 4 hours
  • Bowel necrosis is a rare adverse event that can occur with Kayexalate
  • More myths and misconceptions about hyperkalemia addressed in reference below!


Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022;52:85-91. doi:10.1016/j.ajem.2021.11.030

Mahoney BA, Smith WA, Lo DS, Tsoi K, Tonelli M, Clase CM. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev. 2005;2005(2):CD003235. Published 2005 Apr 18. doi:10.1002/14651858.CD003235.pub2

Li T, Vijayan A. Insulin for the treatment of hyperkalemia: a double-edged sword?. Clin Kidney J. 2014;7(3):239-241. doi:10.1093/ckj/sfu049

Summarized by Mason Tuttle| Edited by Nick Tsipis, MD