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- Discussion:
    - diff dx:
    - physical exam:
            - neuromuscular: weakness, paresthesia, depressed tendon reflexes;
    - assess severity:
            - K > 8.0 mmol/L, EKG w/ more than peaked T waves alone, or if cause is not immediately remediable;
            - hyperkalemia may worsen CHF, DKA, acute dehydration, extensive tissue breakdown (burns), or adrenal insufficiency;

- Acute HyperK > 6.5:
    - monitoring and precautions:
          - EKG monitoring, if K > 6.5 mmol/L;
          - caution if pt is on digoxin (may precipitate ventricular dysrhythmia);
          - monitor K+ concentration every 1-2 hrs until it is < 6.5 mmol/L;
    - medications:
          - Ca gluconate 5-10ml 10% IV over 5 min;
                  - will antagonize cardiac & neuromuscular effects of hyperK, effects will last for 1 hr, will not reduce K+ level;
          - HCO3:
                  - 1amp = 7.5% = 44.6mEq in 5min
                  - effects are immediate and lasts for 1-2 hrs;
          - glucose:
                  - D50W: 50 ml IV followed by regular insulin 5-10 units IV will shift K+ from the ECF to the ICF;
                  - its effects are immediate and lasts for 1-2 hrs; or try:
                  - 1 amp of glucose (25gm in 5min) w/ Reg insulin 10 units IV;
          - glucose-insulin-HCO3 "cocktail":
                  - D10W 1000 ml w/ 3 ampules of NaHCO3 & 20 units of regular insulin at 75 ml/hr until more definite measures are taken;
          - kayexalate:
                  - 15-30 gm (4-8 tsp) in 50 to 100 ml of 20% sorbitol PO q3-4 hrs, or 50 gm in 200 ml 20% sorbitol or D20W PR by retention enema for 30-60 min q4hr;
                  - kayexalate: 1gm resin rids 1mEq K; 1teasp = 3.5gm;
                  - careful with CHF, HTN, constipation;
                  - may also try 15-30gm Kay w/ 50-100ml 20%Sorbitol or 20% DW;
    - hemodialysis:
          - if other measure fail or if the patient is in acute or chronic renal failure