A 55-year-old woman has serum potassium of 6.8 mEq/L. ECG shows peaked T waves, widened QRS, and prolonged PR interval. She is on ACE inhibitor and has CKD stage 4. What is the correct sequence of emergency management?
- A IV insulin + dextrose → sodium bicarbonate → haemodialysis → calcium gluconate
- B IV calcium gluconate (cardiac membrane stabilisation) → IV insulin + 50% dextrose → sodium bicarbonate → ion exchange resin or haemodialysis ✓
- C Sodium polystyrene sulphonate orally → IV furosemide → calcium gluconate
- D IV salbutamol nebulisation → calcium gluconate → haemodialysis
Correct answer: B. IV calcium gluconate (cardiac membrane stabilisation) → IV insulin + 50% dextrose → sodium bicarbonate → ion exchange resin or haemodialysis
Explanation
In severe hyperkalaemia with ECG changes, the immediate priority is cardiac membrane stabilisation with IV calcium gluconate (10 mL of 10% solution over 2–3 minutes) — this does not lower potassium but antagonises its membrane effects within minutes. Next, potassium shifts are achieved with IV insulin + dextrose and sodium bicarbonate. Definitive potassium removal uses sodium polystyrene sulphonate, patiromer, sodium zirconium cyclosilicate, or haemodialysis for refractory cases.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.