Adult Medical Emergency Handbook - Scottish Intensive Care Society

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1. IMMEDIATE ACTION: STABILISATION
• Assess ABCDE and treat accordingly.
• Correct hypoxaemia.
• IV access.
• Continuous ECG monitoring is mandatory.
• Monitor oxygen saturation.
• Specific treatment depends on ECG changes and potassium
concentration.
• If ECG shows peaked T waves or more severe changes titrate IV
calcium gluconate 10% or calcium chloride 10% in 1 ml aliquots
watching the ECG. The trace will normalise as the calcium takes
effect. If too much IV calcium is given it can result in cardiac arrest
in asystole. The required amount varies from 2 or 3 mls to 20mls.
This simply stabilises the myocardium giving time to institute
therapy to reduce the potassium. This may need to be repeated.
• In cardiac arrest follow ALS algorithm and give 10mls 10%
calcium chloride IV. VF will be resistant to defibrillation if calcium
not given.
2. REDUCING THE POTASSIUM
• Bolus IV dextrose 50ml 50% solution with 5-10iu Actrapid (or
equivalent e.g. Humulin S). Takes 20-30 mins to work.
• This can be followed with a slow infusion of 10% or 20% dextrose
running at between 10ml/hr and 50ml/hr. Monitor blood sugar
regularly and add insulin as required.
• Nebulised salbutamol 5mg and repeated.
• Sodium bicarbonate 1.26% IV infusion. Start at 100ml/hr and
titrate to HCO 3 and K + levels. Not for routine use. May help:
discuss with renal registrar RIE or ICU, WGH/SJH.
3. ELIMINATING THE POTASSIUM
• The best way of removing potassium is to restore urine output and
recover renal function.
• Failing this potassium removal by haemodialysis or
haemofiltration may be required.
Stop dextrose and insulin infusions to allow potassium to
re-enter the blood, thus making it available for removal in the
dialyser.
188 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11