Definition (as from ALS 2 Manual): >5.5 mmol/L
- Severe hyperkalaemia: >6.5 mmol/L

Aetiologies

Renal failure
Drugs (ACE-i, ARB, potassium sparing diuretics, NSAIDs, ß-blockers, trimethoprim)
Tissue breakdown (e.g. rhabdomyolysis, tumour lysis, haemolysis, burns)
Metabolic acidosis (e.g. renal failure, diabetic ketoacidosis)
Endocrine disorders (e.g Addison disease)
Pseudo-hyperkalaemia secondary to prolonged transit time or poor storage conditions

Clinical Features

Fluid resuscitation in order to enhance renal perfusion and elimination
Membrane stabilisation with calcium
- 5-10 mL of calcium 10% gluconate (2.2 mmol Ca ions) or 10% chloride (6.8 mmol Ca ions) over 2-5 minutes
Shift potassium into cells
- Bicarbonate infusion 50-100mL of 8.4% (1 mmol/kg) IV over 5 minutes
  - Requires a metabolic acidosis to be present
  - Do not administer at same time as calcium as it can cause precipitation
- Insulin/dextrose infusion
  - 10U actrapid + 50mL of 50% glucose
  - Reduces potassium by 0.65-1 mmol/L/hr
- Salbutamol nebulisers or IV
  - 0.5 mg IV or 20 mg (2-4 nebs) nebulised
Increase potassium excretion
- Diuretics
  - Mannitol and frusemide theoretically work but are not routinely used in hyperkalaemia management
- Dialysis
- Resonium
  - Rare side effect of intestinal necrosis in patients with bowel obstruction, ileus or opioid use

Give 10 mL of 10% calcium chloride IV by rapid bolus injection (calcium gluconate when chloride not available noting that it has 1/3 calcium ions)
Give insulin 10 units (actrapid) and 25 g glucose IV by rapid injectiona
Give sodium bicarbonate 50mmol IV by rapid injection if severe acidosis or renal failure (do not give by the same line as the calcium chloride)
Consider dialysis
Adrenaline may help drive potassium down

Start resuscitation as per standard ALS pathway
Assign a dialysis nurse to the machine to:
- Stop ultrafiltration
- Give a fluid bolus
- Return the patient’s blood volume and disconnect from the dialysis machine
Leave dialysis access open and use for drug administration
Urgent defibrillation (VF, pVT) is common in haemodialysis patients (most machines recommend discconection from the dialysis equipment prior to defibrillation)