Indicated if there are any ECG changes or evidence of arrhythmias. Consider if K >7 mEq/L
Either one of the following:
Calcium gluconate: Give 10ml of a 10% solution (1 gram) over 5-10 mins. In severe cases may have to start with higher dose of 3 grams (30 mLs) and repeat doses (up to 9-15 grams total).
Only 1/3 the elemental calcium compared to calcium chloride.
Can cause hypotension due to osmotic shift
Calcium chloride 1 gram IV
Give over 1 - 2 minutes
Extravasation is bad: use a good IV
Usually given in code situations
Takes effect in 15-30 minutes
(If given for<unk>  cardiac arrest, need to continue resuscitation for at least 30 minutes)
Duration of action: 30 - 60 minutes 
Use caution in patients taking Digoxin although risk of Stone heart may be unsubstantiated 
Do serial ECGs to track progress: may need to give multiple doses
Calcium gluconate: Give 10ml of a 10% solution (1 gram) over 5-10 mins. In severe cases may have to start with higher dose of 3 grams (30 mLs) and repeat doses (up to 9-15 grams total).
Only 1/3 the elemental calcium compared to calcium chloride.
Can cause hypotension due to osmotic shift
Calcium chloride 1 gram IV
Give over 1 - 2 minutes
Extravasation is bad: use a good IV
Usually given in code situations
Only 1/3 the elemental calcium compared to calcium chloride.
Can cause hypotension due to osmotic shift
Give over 1 - 2 minutes
Extravasation is bad: use a good IV
Usually given in code situations
(If given for<unk>  cardiac arrest, need to continue resuscitation for at least 30 minutes)
Intravenous insulin + dextrose
Give 10 units regular insulin intravenously with 25 to 50 grams (1 - 2 50 mL ampules) of 50% dextrose (D50)
May withhold dextrose if blood sugar >300mg/dl (>17 mmol/L)
Duration of effect: 4 - 6 hours
Consider mixing in 10 cc NS syringe to ensure small volume of 10 units insulin fully administered via IV
Insulin cleared renally, be careful about inducing hypoglycemia (ESRD patients).
In a small 2017 retrospective cohort study, researchers found that giving 5 units of insulin instead of 10 units reduced serum potassium to the same extent as 10 units, with a lower rate of hypoglycemia.
Consider decreasing to 5 units or increasing dextrose dose to 50g with following risk factors: pretreatment blood glucose <150, acute kidney injury/chronic kidney disease, no history of DM, weight <60kg, female sex 
Nebulized albuterol 15 - 20mg
Response is dose-dependent
Peak effect: 30 minutes
Duration of effect: 2 hours
Sodium bicarbonate
Generally not considered unless pH <7.1
Pushing "ampules of hypertonic bicarbonate have been proven to be ineffective in RCTs"
For normovolemic or hypovolemic patients with metabolic acidosis:
Give three amps of bicarbonate in a liter of D5W or sterile water
Give 10 units regular insulin intravenously with 25 to 50 grams (1 - 2 50 mL ampules) of 50% dextrose (D50)
May withhold dextrose if blood sugar >300mg/dl (>17 mmol/L)
Duration of effect: 4 - 6 hours
Consider mixing in 10 cc NS syringe to ensure small volume of 10 units insulin fully administered via IV
Insulin cleared renally, be careful about inducing hypoglycemia (ESRD patients).
In a small 2017 retrospective cohort study, researchers found that giving 5 units of insulin instead of 10 units reduced serum potassium to the same extent as 10 units, with a lower rate of hypoglycemia.
Consider decreasing to 5 units or increasing dextrose dose to 50g with following risk factors: pretreatment blood glucose <150, acute kidney injury/chronic kidney disease, no history of DM, weight <60kg, female sex 
May withhold dextrose if blood sugar >300mg/dl (>17 mmol/L)
Duration of effect: 4 - 6 hours
Consider mixing in 10 cc NS syringe to ensure small volume of 10 units insulin fully administered via IV
Insulin cleared renally, be careful about inducing hypoglycemia (ESRD patients).
In a small 2017 retrospective cohort study, researchers found that giving 5 units of insulin instead of 10 units reduced serum potassium to the same extent as 10 units, with a lower rate of hypoglycemia.
Consider decreasing to 5 units or increasing dextrose dose to 50g with following risk factors: pretreatment blood glucose <150, acute kidney injury/chronic kidney disease, no history of DM, weight <60kg, female sex 
In a small 2017 retrospective cohort study, researchers found that giving 5 units of insulin instead of 10 units reduced serum potassium to the same extent as 10 units, with a lower rate of hypoglycemia.
Consider decreasing to 5 units or increasing dextrose dose to 50g with following risk factors: pretreatment blood glucose <150, acute kidney injury/chronic kidney disease, no history of DM, weight <60kg, female sex 
Response is dose-dependent
Peak effect: 30 minutes
Duration of effect: 2 hours
Generally not considered unless pH <7.1
Pushing "ampules of hypertonic bicarbonate have been proven to be ineffective in RCTs"
For normovolemic or hypovolemic patients with metabolic acidosis:
Give three amps of bicarbonate in a liter of D5W or sterile water
Give three amps of bicarbonate in a liter of D5W or sterile water
Intravenous furosemide (Lasix) 40 - 80mg
Ensure adequate urine output first
Decreases the potassium in three ways: dilution, shifting of potassium into muscle cells, and promotion of renal potassium excretion by alkalosis
More on how to use Lasix: IBCC<unk>  Chapter
Sodium polystyrene sulfonate (Kayexalate): 30 gm oral or per rectum
Very Controversial, High Risk of Bowel Perforation, see: EBQ: Use of Kayexylate in<unk> 
Sodium zirconium cyclosilicate
Potassium binder, similar to Kayexalate but without risk of bowel perforation
Intravenous lactated ringers solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis (avoid NS, causes hyperchloremic acidosis which shifts potassium out of cells increasing level)
consider isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter), can calculate bicarbonate deficit then divide by 150mEq/L to estimate number of liters of isotonic bicarbonate required) 
Hydrocortisone if suspicious for adrenal insufficiency
Definitive treatment is hemodialysis
Ensure adequate urine output first
Decreases the potassium in three ways: dilution, shifting of potassium into muscle cells, and promotion of renal potassium excretion by alkalosis
More on how to use Lasix: IBCC<unk>  Chapter
Very Controversial, High Risk of Bowel Perforation, see: EBQ: Use of Kayexylate in<unk> 
Potassium binder, similar to Kayexalate but without risk of bowel perforation
consider isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter), can calculate bicarbonate deficit then divide by 150mEq/L to estimate number of liters of isotonic bicarbonate required) 
LR is preferred over NS, even in renal failure
The small amount of 4 mEq/L of potassium in lactated ringers does not contribute to worsening<unk> <unk>  worsens with metabolic acidosis, and large volume normal saline administration increases risk of hyperchloremic non-anion gap metabolic acidosis
Hyperkalemia
Pseudohyperkalemia: hemolyzed specimen, prolonged tourniquet use prior to blood draw, thrombocytosis or leukocytosis
Hyponatremia
Redistribution 
Hypernatremia
Acidemia 
Hypokalemia
Cellular breakdown: see Rhabdomyolysis/Crush syndrome, electrical/thermal burn, hemolysis, see Tumor lysis syndrome