The 3-Step Approach to Acute Hyperkalemia

1. Stabilize: the Heart (If ECG changes) → Calcium

2. Shift: K+ Into Cells → Insulin + Glucose, Albuterol, Bicarb (if acidotic)

3. Send-it: Remove K+ From Body → Diuretics (if making urine), Kayexalate (if GI motility intact), Dialysis (if severe/refractory)

I – IV Fluids

C – Calcium

B – Beta-2 Agonists

B – Bicarbonate

I – Insulin & Glucose

K – Kayexalate (Sodium Polystyrene Sulfonate)

D – Diuretics

D – Dialysis

1. First Step: Assess ECG & Risk of Arrhythmia

• Peaked T waves, QRS widening, sine wave = Give Calcium ASAP

• Calcium doesn’t lower K+, but it prevents cardiac arrest.

2. Temporary vs. Definitive Treatments

• Shifting K+ into cells (Beta-agonists, Bicarb, Insulin) buys time.

• Excreting K+ (Diuretics, Dialysis, Kayexalate) removes K+.

3. Timing of Interventions:

• Calcium: Immediate (stabilizes heart).

• Insulin/Albuterol/Bicarb: 15–30 min (shifts K+).

• Diuretics/Kayexalate: 1–6 hours (removes K+).

• Dialysis: Immediate, definitive.

4. Common Pitfalls & Pro Tips

• Insulin can cause hypoglycemia – recheck glucose in 30 minutes.

• Albuterol requires high doses – typical 2.5 mg nebs won’t cut it.

• Bicarb only works if acidotic – don’t rely on it in normotensive patients.

• Kayexalate is slow & controversial – consider patiromer or zirconium cyclosilicate instead in chronic cases.

• If oliguric or ESRD → Straight to dialysis.