Hyperkalaemia

Hyperkalaemia (K+ >5.5 mmol/L) is a medical emergency above K+ >6.0 or if ECG changes are present. ECG changes follow a progressive sequence: peaked T waves → PR prolongation → P wave loss → broad QRS → sine wave → VF/asystole. Act before VF.

Hyperkalaemia Management Protocol

The pathway

1 · ECG immediately

Peaked T waves
PR prolongation
Wide QRS
Sine wave pattern
Any ECG changes = treat urgently regardless of K+ level.

2 · Stabilise the membrane

Calcium gluconate 10% 30ml IV over 10 minutes — 6.8mmol calcium (UKKA 2023)
In arrest or peri-arrest: calcium chloride 10% 10ml over 5 minutes is the preferred salt
Protects the heart
Does NOT lower K+
Effect within 3 minutes, lasts 30–60 minutes
Repeat if ECG changes persist.

3 · Shift K+ into cells

Insulin 10 units in 25g glucose IV — 50ml of 50% or 250ml of 10%
If pre-treatment BM <7.0, follow with 10% glucose 50ml/hr for 5 hours
BM at 0, 30, 60, 90 and 120 minutes, then hourly to 6 hours — hourly checks miss early hypoglycaemia
Lowers K+ by 0.5–1.5 mmol/L

4 · Salbutamol nebuliser

10–20mg nebulised
Additive to insulin-dextrose
Lowers K+ by 0.5–1 mmol/L
Caution in ischaemic heart disease.

5 · Remove K+ from body

Sodium zirconium cyclosilicate (SZC) or patiromer — the novel binders, now recommended for moderate and severe hyperkalaemia. Secondary care initiation
Calcium resonium has been REMOVED from the emergency hospital algorithm (UKKA 2023). It remains a short-term option for chronic hyperkalaemia in non-hospitalised patients only
Consider dialysis in AKI with refractory hyperkalaemia
Binders act over hours — they do not replace calcium and insulin-dextrose in an emergency

6 · Treat cause

Stop potassium supplements, potassium-sparing diuretics, ACEi/ARB, NSAIDs. Treat AKI, acidosis, rhabdomyolysis.

7 · Monitor

Repeat K+ at 1 and 2 hours. Continuous cardiac monitoring until K+ <5.5 and no ECG changes.

Drugs

Drug	Dose	Route	Notes
Calcium gluconate 10%	30ml	IV	Over 10 minutes — 6.8mmol calcium. Membrane stabilisation. Calcium chloride 10% 10ml over 5 min is the preferred salt in arrest. Repeat if ECG changes persist.
Actrapid insulin	10 units	IV	In 25g glucose — 50ml of 50% or 250ml of 10%. BM at 0, 30, 60, 90 and 120 minutes, then hourly to 6 hours. If pre-treatment BM <7.0, follow with 10% glucose 50ml/hr for 5 hours (UKKA 2026).
Salbutamol	10–20mg	Nebulised	Additive to insulin/dextrose. Avoid in ischaemic heart disease.
Sodium zirconium cyclosilicate	10g TDS (up to 72h), then 5g OD	Oral	Potassium binder. Replaced calcium resonium in the UKKA 2023 emergency algorithm. Secondary care initiation. Onset ~1h — an adjunct, never a substitute for calcium and insulin-dextrose.
Patiromer	8.4g OD	Oral	Alternative binder, secondary care initiation. Stop if RAASi therapy is stopped. Slower onset than SZC.
Sodium bicarbonate 8.4%	50ml	IV	Not routine for acute hyperkalaemia (UKKA 2026). Only where severe acidosis is being treated in its own right, on senior advice.

When to escalate

K+ >6.5 mmol/L with ECG changes — emergency,VT/VF — ALS,AKI not responding to treatment — dialysis,K+ not falling after two cycles of treatment

Reference: UK Kidney Association — Treatment of Acute Hyperkalaemia in Adults 2023

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