In this episode of IM Basics, Dr. Eric Acker and Dr. Tark break down the essentials of recognizing and managing hyperkalemia, a potentially life-threatening electrolyte disturbance. They discuss common presentations—ranging from dialysis patients to those with tumor lysis syndrome—and highlight key decision points in diagnosis and management.

Topics Covered:

• Common presentations of hyperkalemia and when to suspect it even without classic symptoms.
• ECG findings in hyperkalemia: from peaked T waves to sine waves.
• When to act and how aggressively, based on potassium levels and clinical stability.
• The three pillars of treatment:
  • Cardiac membrane stabilization with calcium gluconate.
  • Potassium shift therapies (e.g., insulin with dextrose, high-dose albuterol).
  • Potassium elimination (e.g., dialysis, Lokelma®, loop diuretics, or rarely, Kayexalate®).
• A practical discussion on the timing of interventions—why and when to delay shifting before dialysis.
• Tips on avoiding overtreatment, interpreting lab errors like pseudohyperkalemia, and reassessing post-intervention.

Clinical Pearls:

• Use calcium gluconate to stabilize membranes, not to lower potassium directly.
• Watch for hyperkalemia in AKI, rhabdomyolysis, tumor lysis syndrome, and missed dialysis.
• Lokelma® has high sodium content—consider alternatives like patiromer in volume-sensitive patients.
• Always reassess potassium after treatment to guide further interventions.

References & Citations:

• Sterns RH. "Hyperkalemia." N Engl J Med. 2022;386(15):1426–1435. DOI: 10.1056/NEJMra2110952.
• Montford JR, Linas S. "How dangerous is hyperkalemia?" J Am Soc Nephrol. 2017;28(11):3155–3165. DOI: 10.1681/ASN.2016121344.
• Kayexalate safety concerns: Patel K, et al. "Sodium polystyrene sulfonate-induced colonic necrosis." Am J Med Sci.2012;343(2):155–157.