Cation exchange resins, such as sodium polystyrene sulfonate have not been shown to decrease the serum potassium level within the first 4 hours of treatment and should not be used alone in the acute management of hyperkalemia.¹²

Critical Decision

When should hemodialysis be initiated in a hyperkalemic patient?

Emergent hemodialysis is the most reliable method of definitively lowering serum potassium in patients with renal failure. Hemodialysis reliably decreases serum potassium levels by at least 1 mEq/L in the first hour and another 1 mEq/L over the next two hours.^7,9,10 It should be instituted early on in the treatment of life-threatening hyperkalemia in patients with renal failure.¹⁰ Hemodialysis should also be the treatment of choice for hyperkalemic patients who have impaired renal function and pulmonary edema caused by fluid overload.

Hemodialysis via central venous access can be used during ongoing cardiopulmonary resuscitation to acutely lower the serum potassium level and may result in return of spontaneous circulation with intact neurologic status despite prolonged resuscitative efforts and failure of conventional medications and defibrillation.¹³

In patients with intact renal function, medical management alone may be sufficient even in extreme cases, and hemodialysis may not be necessary unless multiple medical modalities fail.⁸ These patients should initially be treated medically and hemodialysis delayed until it appears that medical management alone has failed.

Case Resolution

On recognizing life-threatening hyperkalemia in this dialysis-dependent woman, the emergency physician ensured that intravenous access was immediately obtained. Based on the patient’s hyperkalemia with a wide QRS, severe acidemia, and renal failure, she was given one 10-mL ampule of 10% calcium chloride, 10 units of insulin (no glucose was immediately administered because the patient was already hyperglycemic), and one 50-mL ampule of sodium bicarbonate. Nephrology was consulted for emergent hemodialysis.

Summary

Electrolyte abnormalities are very common in emergency medicine practice and rarely occur in isolation. Emergency physicians must be able to identify common disease states that place patients at risk for serious hyperkalemia and initiate appropriate emergency treatment when needed.

References

1. Alfonzo AV, Isles C, Geddes C, Deighan C. Potassium disorders—clinical spectrum and emergency management. Resuscitation. 2006;70:10-25.
2. Slovis C, Jenkins R. ABC of clinical electrocardiography: Conditions not primarily affecting the heart. BMJ. 2002;324(7349):1320-1323.
3. Allon M, Shanklin N. Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol. Am J Kidney Dis. 1996;28:508-514.
4. Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med. 1998;158(8):917-924.
5. Parham WA, Mehdirad AA, Biermann KM, Fredman CS. Hyperkalemia revisited. Tex Heart Inst J. 2006;33(1):40-47.
6. Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. Semin Dial. 2001;14:348-356.
7. Blumberg A, Weidmann P, Shaw S, Gnädinger M. Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. Am J Med. 1988;85(4):507-512.
8. Carvalhana V, Burry L, Lapinsky SE. Management of severe hyperkalemia without hemodialysis: case report and literature review. J Crit Care. 2006;21(4):316-321.
9. Allon M, Dunlay R, Copkney C. Nebulized albuterol for acute hyperkalemia in patients on hemodialysis. Ann Intern Med. 1989;110(6):426-429.
10. Mahoney BA, Smith WA, Lo DS, et al. Emergency interventions for hyperkalaemia. Cochrane Database of Syst Rev. 2005;(2):CD003235.
11. Allon M, Copkney C. Albuterol and insulin for treatment of hyperkaelemia in hemodialysis patients. Kidney Int. 1990;38:869-872.
12. Gruy-Kapral C, Emmett M, Santa Ana CA, et al. Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease. J Am Soc Nephrol. 1998;9(10):1924–1930.
13. 13. Lin JL, Lim PS, Leu ML, Huang CC. Outcomes of severe hyperkalemia in cardiopulmonary resuscitation with concomitant hemodialysis. Intensive Care Med. 1994;20(4):287-290.

Contributor Disclosures

Contributors

Dr. Pfennig is assistant professor of emergency medicine and director of undergraduate medical education in the Department of Emergency Medicine at Vanderbilt University in Nashville, Tenn. Dr. Whitmore is a clinical instructor and critical care fellow in the Department of Emergency Medicine at the University of Arizona College of Medicine. Dr. Slovis is professor of medicine and emergency medicine, chairman of the Department of Emergency Medicine at Vanderbilt University School of Medicine, and medical director of the Nashville Fire Department and International Airport in Nashville. Robert C. Solomon, MD, is Medical Editor of ACEP News and editor of the “Focus On… Critical Decisions” series, core faculty in the emergency medicine residency at Allegheny General hospital, Pittsburgh, and assistant professor in the Department of Emergency Medicine at Temple University School of Medicine, Philadelphia. Mary Anne Mitchell is an ACEP staff member who reviews and manages the ACEP “Focus On… Critical Decisions” series.

Disclosures

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). The American College of Emergency Physicians is accredited by the ACCME to provide continuing medical education for physicians.