Acute severe hyperkalaemia: emergency management algorithm

Also known as Hyperkalaemia · High potassium · Potassium emergency · Hyperkalemia

Hyperkalaemia: UKKA/ERC threshold K+ ≥5.5 mmol/L (mild 5.5–5.9, moderate 6.0–6.4, severe ≥6.5); some reviews use >5.0. SEVERE (≥6.5 or ECG changes): life-threatening arrhythmia. Causes: AKI/CKD, rhabdomyolysis, tumour lysis, drugs (ACEi/ARB, K-sparing diuretics, TMP-SMX, heparin), Addison's, acidosis. ECG changes may be absent (only 55% of a 344-patient cohort had any change). Management: (1) STABILISE membrane with IV calcium (UKKA equivalent 6.8 mmol Ca2+). (2) SHIFT (insulin/glucose, salbutamol). (3) REMOVE (diuretics, binders, dialysis).

high27 referencesUpdated 3 Sept 202630 min readSource-verified · Sept 2026

Checked against its sources on 3 Sept 2026

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8 MCQs

Meet the patient

A 72-year-old with CKD stage 4, on perindopril, spironolactone and trimethoprim-sulfamethoxazole for a urinary tract infection, arrives weak and presyncopal. Heart rate 44, BP 92/58. The venous gas reads K+ 7.4 mmol/L, pH 7.28, bicarbonate 16. The ECG shows a wide QRS at 134 ms with peaked, tented T waves in V2-V4 and absent P waves.^[16]^[15]

This is the prototypical ICU stem, and it asks the one question every paper repeats: what is the first drug, and why does the order matter? The answer — calcium before anything that lowers potassium — is the most testable fact in the topic, and the one juniors invert.^[3]

References27Show

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