A 22-year-old man with advanced Burkitt lymphoma starts combination chemotherapy. Twelve hours later he has a potassium of 6.8 mmol/L, phosphate 9.5 mg/dL, calcium 6.1 mg/dL, uric acid 18 mg/dL, and peaked T waves on ECG. What is the immediate priority in management?

• A Intravenous furosemide to force diuresis
• B Allopurinol to reduce uric acid formation
• C Emergency dialysis consultation alone
• D Intravenous calcium gluconate followed by cardiac monitoring ✓

Explanation

This is tumor lysis syndrome with life-threatening hyperkalemia and ECG changes. The immediate step is cardiac membrane stabilization with IV calcium gluconate, then shifting potassium with insulin-dextrose and salbutamol. Allopurinol or rasburicase addresses uric acid but works too slowly to protect against fatal arrhythmia. Dialysis may be needed later if potassium cannot be controlled, but it is never the first maneuver in a symptomatic hyperkalemic patient.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.