Adult Hyperkalemia — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Assess urgency
   Any of: ECG changes / serum K ≥6.5 mmol/L / symptomatic? (First exclude pseudohyperkalemia (hemolysis, fist-clenching during draw, very high platelets/WBC). Acute hyperkalemia is more dangerous than chronic (e.g. dialysis patients). Mild 5.5–5.9, moderate 6.0–6.4, severe ≥6.5 mmol/L. ECG: peaked T waves, loss of P waves, PR prolongation, QRS widening, sine wave.)
   • Yes (ECG change / K ≥6.5 / symptomatic) → Emergency treatment · stabilize–shift–remove
   • No (K 5.5–6.4, normal ECG, asymptomatic) → Non-emergency management
2. [End] Emergency treatment · stabilize–shift–remove
   1) Stabilize the myocardium (if ECG changes): 10% calcium gluconate 10–30 mL IV (or 10% calcium chloride 10 mL) over 2–5 min, onset 1–3 min, lasts 30–60 min, repeat as needed; give slowly in patients on digoxin. 2) Shift into cells: regular insulin 10 U + 25 g glucose (50% glucose 50 mL) IV, onset 20–30 min (5 U in CKD/small patients), monitor glucose to prevent hypoglycemia; ± nebulized salbutamol 10–20 mg. 3) Remove from the body: hemodialysis (definitive treatment of choice in refractory/anuric patients); loop diuretic (if residual renal function); oral potassium binder (sodium zirconium cyclosilicate / patiromer). Consider sodium bicarbonate only with concurrent metabolic acidosis. (Note: Also: stop all exogenous potassium and provoking drugs (RAASi, potassium-sparing diuretics, NSAIDs, co-trimoxazole, potassium supplements, low-sodium salt substitutes); continuous ECG monitoring; recheck potassium and glucose at 30 min and beyond. Calcium only stabilizes (does not lower K); insulin/β2 only shift (do not reduce total K).)
3. [End] Non-emergency management
   Stop provoking drugs (RAASi, potassium-sparing diuretics, NSAIDs, potassium supplements, low-sodium salt substitutes); find and correct the cause (AKI/CKD, metabolic acidosis, tissue necrosis/hemolysis, adrenal insufficiency); potassium-restricted diet; consider an oral potassium binder (sodium zirconium cyclosilicate / patiromer); a loop diuretic if residual renal function. (Note: Recheck potassium to confirm the trend; monitor continuously and move to the emergency track if it rises to ≥6.5 or ECG changes appear. Chronic dialysis patients often tolerate mild hyperkalemia — manage per the dialysis plan.)

Source guidelines & references

• UKKA 2023 Clinical Practice Guidelines: Treatment of Acute Hyperkalaemia in Adults · source ↗
• KDIGO 2018 Conference on acute hyperkalemia. Kidney Int / Eur J Emerg Med 2020

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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