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Nephrology Electrolyte Emergencies Intermediate
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Hyperkalemia Management Protocol: C BIG K DROP

C
BIG
K
DROP
Step-by-step emergency medical stabilization and total body elimination of severe hyperkalemia (K+ > 6.5 mEq/L or with ECG changes).

Hyperkalemia decreases myocardial resting membrane potential, leading to peaked T waves, PR prolongation, widened QRS, and fatal sine waves. Treatment prioritizes cardiac membrane stabilization first, intracellular shifting second, and definitive bodily excretion third.

Systematic Breakdown

C

Calcium Gluconate / Calcium Chloride

Step 1: Membrane stabilization. Antagonizes membrane excitability immediately (within 1-3 minutes); does NOT lower serum potassium level.

B

Beta-2 Agonists (Albuterol / Salbutamol)

Step 2: Intracellular shift. High-dose nebulized albuterol (10-20 mg) stimulates Na+/K+-ATPase, shifting potassium into cells.

I

Insulin (Regular) + Glucose

Step 2: Intracellular shift. 10 units IV Regular Insulin + 25-50g Dextrose (D50W) shifts potassium into skeletal muscle within 15-30 minutes.

G

Glucose (Dextrose)

Prevents severe hypoglycemia caused by therapeutic insulin bolus (check glucose frequently).

K

Kayexalate / Patiromer / ZS-9

Step 3: Elimination. Potassium-binding resins in the gastrointestinal tract exchanging sodium or calcium for potassium.

D

Diuretics (Furosemide)

Step 3: Elimination. Loop diuretics promote kaliuresis if patient has residual renal function.

ROP

Renal Dialysis (Hemodialysis)

Step 3: Elimination. The most rapid and definitive elimination method for refractory hyperkalemia or end-stage kidney disease.

High-Yield Clinical Pearls & Exam Tips
  • ECG Progression: Peaked T waves -> PR prolongation & flat P waves -> QRS widening -> Sine wave -> Ventricular fibrillation / Asystole.
  • Calcium chloride provides 3x more elemental calcium than calcium gluconate, but gluconate is preferred via peripheral IV due to lower tissue necrosis risk if extravasated.
Related Pharmaceuticals
Calcium Gluconate Regular Insulin Dextrose 50% Albuterol Sodium Polystyrene Sulfonate
Related Clinical Conditions
Acute Kidney Injury End-Stage Renal Disease Tumor Lysis Syndrome Rhabdomyolysis
Authoritative Sources: AHA Guidelines on Electrolyte Emergencies · First Aid USMLE Step 1

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