Controversies in Management of Hyperkalemia

J Emerg Med. 2018 Aug;55(2):192-205. doi: 10.1016/j.jemermed.2018.04.004. Epub 2018 May 3.


Background: Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately.

Objectives: This review evaluates the classic treatments of hyperkalemia and discusses controversies and new medications for management.

Discussion: Potassium (K+) plays a key role in determining the transmembrane potentials of "excitable membranes" present in nerve and muscle cells. K+ is the predominant intracellular cation, and clinical deterioration typically ensues when patients develop sufficiently marked elevation in extracellular fluid concentrations of K+ (hyperkalemia). Hyperkalemia is usually detected via serum clinical laboratory measurement. The most severe effect of hyperkalemia includes various cardiac dysrhythmias, which may result in cardiac arrest and death. Treatment includes measures to "stabilize" cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion. Calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted. Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin. Dextrose should also be administered, as indicated by initial and serial serum glucose measurements. Dialysis is the most efficient means to enable removal of excess K+. Loop and thiazide diuretics can also be useful. Sodium polystyrene sulfonate is not efficacious. New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise.

Conclusions: Hyperkalemia can be deadly, and treatment requires specific measures including membrane stabilization, cellular shift, and excretion.

Keywords: acidosis; beta-agonist; calcium; cardiac arrest; dialysis; diuresis; electrocardiogram; excretion; hyperkalemia; insulin; patiromer; sodium polystyrene sulfonate; sodium zirconium cyclosilicate.

Publication types

  • Review

MeSH terms

  • Acidosis / drug therapy
  • Buffers
  • Cation Exchange Resins / therapeutic use
  • Dialysis / methods
  • Drug Combinations
  • Electrocardiography / methods
  • Glucose / therapeutic use
  • Humans
  • Hyperkalemia / diagnosis
  • Hyperkalemia / therapy*
  • Hypoglycemia / drug therapy
  • Hypoglycemia / etiology
  • Insulin / adverse effects
  • Insulin / therapeutic use
  • Polystyrenes / therapeutic use
  • Potassium / analysis
  • Potassium / blood
  • Receptor, Insulin / adverse effects
  • Receptor, Insulin / therapeutic use
  • Sodium Bicarbonate / therapeutic use
  • Transcytosis / drug effects
  • Transcytosis / physiology
  • Treatment Outcome*


  • Buffers
  • Cation Exchange Resins
  • Drug Combinations
  • Insulin
  • Polystyrenes
  • polystyrene sulfonic acid
  • Sodium Bicarbonate
  • Receptor, Insulin
  • Glucose
  • Potassium