Acker CG, Johnson JP, Palevsky PM, Greenberg A Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Archives of Internal Medicine. 1998; 158:917-24

Alfonzo AV, Isles C, Geddes C, Deighan C Potassium disorders – clinical spectrum and emergency management. Resuscitation. 2006; 70:10-25

Allon M, Copkney C Albuterol and insulin for treatment of hyperkalaemia in haemodialysis patients. Kidney International. 1990; 38:869-72

Allon M, Dunlay R, Copkney C Nebulised albuterol for acute hyperkalaemia in patients on haemodialysis. Annals of Internal Medicine. 1989; 110:426-9

Allon M, Shanklin N Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol. American Journal of Kidney Disease. 1996; 28:508-14

An JN, Lee JP, Jeon HJ, Kim do H Severe hyperkalemia requiring hospitalization: predictors of mortality. Critical Care. 2012; 16

Bass V Pharmaceutical Drugs For Cardiovascular System Diseases.London: World Technologies; 2012

Batterink J, Cessford TA, Taylor RAI Pharmacological interventions for the acute management of hyperkalaemia in adults. Cochrane Database of Systematic Reviews (online). (10). 2015;

Blumberg A, Weidmann P, Ferrari P Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure. Kidney International. 1992; 41:369-74

Blumberg A, Weidmann P, Shaw S, Gnädinger M Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. American Journal of Medicine. 1988; 85:507-12

Davey M, Caldicott D Calcium salts in management of hyperkalaemia. Emergency Medical Journal. 1992; 19:92-3

Davis TR, Young BA, Eisenberg MS, Rea TD Outcome of cardiac arrests attended by emergency medical services staff at community outpatient dialysis centers. Kidney International. 2008; 73:933-9

Elliott MJ, Ronksley PE, Clase CM, Ahmed SB Management of patients with acute hyperkalemia. Canadian Medical Association Journal. 2010; 182:1631-5

Gennari FJ Disorders of potassium homeostasis. Hypokalemia and hyperkalemia. Critical Care Clinics. 2002; 18:273-88

Giebisch G Renal potassium transport: mechanisms and regulation. American Journal of Physiology. 1998; 274:817-33

Greenberg A Hyperkalemia: treatment options. Seminars. Nephrology. 1998; 18:(1)46-57

Gutierrez R, Schlessinger F, Aster J, Rietberg B, Perez GO Effect of hypertonic versus isotonic sodium bicarbonate on plasma concentration in patients with end-stage renal disease. Mineral and Electrolyte Metabolism. 1991; 17:297-302

Hsieh MF, Wu IW, Lee CC, Wang SY, Wu MS Higher serum potassium level associated with late stage chronic kidney disease. Chang Gung Medical Journal. 2011; 34:418-25

Hollander-Rodriguez JC, Calvert JF Hyperkalaemia. American Family Physcian. 2006; 73:(2)283-90

UK Ambulance Service Clinical Practice Guidelines: Cardiac Arrest.London: Edexcel Publication; 2013a

UK Ambulance Service Clinical Practice Guidelines: Salbutamol.London: Edexcel Publication; 2013b

Lawrence S, Weisburg MD Management of severe hyperkalemia. Critical Care Medicine. 2008; 36:(12)3246-51

Lens XM, Montoliu J, Cases AJM, Campistol L Treatment of hyperkalaemia in renal failure: salbutamol vs insulin. Nephrology Dialysis Transplantation. 1989; 4:228-32

Lin CH, Tu YF, Chiang WC, Wu SY Electrolyte abnormalities and laboratory findings in patients with out-of-hospital cardiac arrest who have kidney disease. American Journal of Emergency Medicine. 2013; 31:487-93

Liou HH, Chiang SS, Wu SC, Huang TP Hypokalaemic effects of intravenous infusion or nebulisation of salbutamol in patients with chronic renal failure: comparative study. American Journal of Kidney Disease. 1994; 23:266-71

Mahoney B, Smith W, Lo D, Tsoi K Emergency interventions for hyperkalaemia. Cochrane Database of Systematic Reviews. 2005; 18:(2)

Mandelberg A, Krupnik Z, Houri S, Smetana S Salbutamol metered-dose inhaler with spacer for hyperkalaemia. How fast? How safe?. Chest. 1999; 115:617-22

Mattu A, Brady WJ, Robinson DA Electrocardiographic manifestations of hyperkalaemia. American Journal of Emergency Medicine. 2000; 18:721-9

Maxwell AP, Linden K, O'Donnell S, Hamilton PK, McVeigh GE Management of hyperkalaemia. Joint Royal College of Physcians Edinburgh. 2013; 43:246-51

McClure RJ, Prasad VK, Brocklebank JT Treatment of hyperkalaemia using intravenous and nebulised salbutamol. Archives of Disease in Childhood. 1994; 70:126-8

Meaney PA, Nadkarni VM, Kern KB, Indik JH Rhythms and outcomes of adult in-hospital cardiac arrest. Critical Care Medicine. 2010; 38:101-8

Melnyk BM, Fineout-Overholt E Evidence-Based Practice in Nursing and Healthcare: a guide to best practice, 2nd ed. Philadelphia: Lippincott, Williams and Wilkins; 2011

Moore ML, Bailey RR Hyperkalaemia in patients in hospital. New Zealand Medical Journal. 1989; 102:557-8

Ngugi N, McLigeyo S, Kayima J Treatment of hyperkalaemia by altering the transcellular gradient in patients with renal failure: effect of various therapeutic approaches. East African Medical Journal. 1997; 74:503-9

Noize P, Bagheri H, Durrieu G, Haramburu F Life-threatening drug-associated hyperkalemia: a retrospective study from laboratory signals. Pharmacoepidemiol and Drug Safety. 2011; 20:747-53

Nyirenda MJ, Tang JI, Padfield PL, Seckl JR Hyperkalaemia. British Medical Journal. 2009; 339:1019-24

Paice B, Gray JM, McBride D, Donnelly T Hyperkalaemia in patients in hospital. British Medical Journal (Clinical Research Edition). 1983; 286:1189-92

Palmer BF Regulation of potassium homeostasis. Clinical Journal of the American Society of Nephrology. 2014;

Smellie WS Spurious hyperkalaemia. British Medical Journal. 2007; 334:693-5

Trust Clinical Guideline: Patient Group Directive – Calcium Chloride 10%.Exeter: NHS Publication; 2014

Trust Clinical Guideline: Patient Group Directive – Sodium Bicarbonate.Exeter: NHS Publication; 2013

Strange B Prehospital treatment of hyperkalaemia. Journal of Paramedic Practice. 2010; 2:(5)194-9

Szerlip HM, Weiss J, Singer I Profound hyperkalemia without electrocardiographic manifestations. American Journal of Kidney Disease. 1986; 7:461-5

Truhlár A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A European resuscitation council guidelines for resuscitation 2015. section 4. Cardiac arrest in special circumstances. Resuscitation. 2015; 95:148-201

Treatment of acute hyperkalaemia in adults.Oxford: Oxford University Press; 2014

Vandan Hoek TLV, Morrison LJ, Shuster M, Donnino M 2010 American heart association guidelines for cardiopulmonary. Part 12: Cardiac Arrest in Special Situations. Circulation. 2010; 122:829-61

Wang CH, Huang CH, Chang WT, Tsai MS The effects of calcium and sodium bicarbonate. Resuscitation. 2016; 98:105-11

Weisberg LS Management of severe hyperkalaemia. Critical Care Medicine. 2008; 36:3246-51

Williams ME, Gervino EV, Rosa RM, Landsberg L Catecholamine modulation of rapid potassium shifts during exercise. New England Journal of Medicine. 1985; 312:(13)823-7

You JS, Park YS, Chung HS, Lee HS Evaluating the utility of rapid point-of-care potassium testing for the early identification of hyperkalemia in patientswith chronic kidney disease in the emergency department. Yonsei Medical Journal. 2014; 55:1348-53

Paramedic management of out-of-hospital cardiac arrest secondary to hyperkalaemia

02 June 2017
Volume 9 · Issue 6


Hyperkalaemia is a potentially life-threatening metabolic emergency and is the most common electrolyte disorder associated with death. The author attended an incident where a patient suffered asystolic cardiac arrest from hyperkalaemia and was subsequently resuscitated successfully to hospital discharge with good neurological outcome. This piece intends to review all relevant available literature with the aim of developing recommendations to aid paramedics in managing cardiac arrest secondary to Hyperkalaemia. Despite the lack of current good-quality evidence for pharmacological interventions, systematic reviews available have led to the development of clear guidelines. The use of calcium chloride and sodium bicarbonate is recommended, and these are both carried by Critical Care Paramedics (CCPs). Salbutamol therapy has the strongest evidence base of any intervention available out of hospital. It should be considered after the use of the aforementioned medications if the patient achieves ROSC. Consideration must also be taken as to whether the patient would benefit from being moved to hospital to reach vital interventions such as insulin/dextrose therapy and dialysis.

Hyperkalaemia is a potentially life-threatening metabolic emergency that can be encountered in a variety of clinical settings (Acker et al, 1998) and is the most common electrolyte disorder associated with death (Smellie, 2007). It is caused when the kidneys are unable to properly excrete potassium or if the mechanisms that move potassium across the cell membrane are impaired (Hollander-Rodriguez and Calvert, 2006). The frequency of hyperkalaemia has recently been documented as high as 40–50% in patients with chronic kidney disease (CKD) and 2–3% in the general population (Kovesdy, 2014). Moreover, Lin et al (2013) found severe hyperkalaemia to be responsible for 32% of out-of-hospital cardiac arrests (OHCA). Cardiac arrest secondary to hyperkalaemia is rare but potentially reversible even after protracted resuscitation efforts (Alfonzo, 2006). Early recognition and swift treatment of this disorder can result in successful patient outcomes (Maxwell et al, 2013). Despite this, anecdotally, paramedics are seldom aware of the signs, symptoms and medical history that is indicative of hyperkalaemia and how to manage it if suspected. After presenting a case study, this article will review the pathophysiology of hyperkalaemia, current guidelines and all relevant available literature with the aim of developing recommendations to aid paramedics in delivering high-quality pre-hospital care.

Subscribe to get full access to the Journal of Paramedic Practice

Thank you for visiting the Journal of Paramedic Practice and reading our archive of expert clinical content. If you would like to read more from the only journal dedicated to those working in emergency care, you can start your subscription today for just £48.

What's included

  • CPD Focus

  • Develop your career

  • Stay informed