Ione
Disorders
Aetiology
Signs
EKG changes
Treatment
K+
Hyperkalaemia mild
(5–6 mEq/L)
Drugs
End-stage renal disease
Rhabdomyolysis
Metabolic acidosis
Pseudohyperkalaemia
Hemolysis
Tumour lysis syndrome
Diet
Hypoaldosteronism (Addison disease, hyporeninemia)
Type 4 renal tubular acidosis
Hyperkalaemic periodic paralysis
Weakness
Ascending paralysis
Respiratory failure
Flattened P waves
Prolonged PR interval
Widened QRS complex
Deepened S waves
Merging of S and T waves
Sine-wave pattern
Idioventricular rhythm
Asystolic cardiac arrest
1. Furosemide 1 mg/kg IV slowly
2. Kayexalate 15–30 g in 50–100 mL of 20 % sorbitol
Hyperkalaemia moderate
(6–7 mEq/L)
1. Sodium bicarbonate—50 mEq IV over 5 min
2. Glucose plus insulin—mix 50 g glucose and 10 U regular insulin and give IV over 15–30 min
3. Nebulised albuterol 10–20 mg nebulised over 15 min
Hyperkalaemia severe
(>7 mEq/L)
1. Calcium chloride (10 %): 500–1000 mg (5–10 mL) IV over 2–5 min
2. Sodium bicarbonate: 50 mEq IV over 5 min
3. Glucose plus insulin: mix 25 g (50 mL of D50) glucose and 10 U regular insulin and give IV over 15–30 min
4. Nebulised albuterol: 10–20 mg nebulised over 15 min
5. Furosemide 40–80 mg IV)
6. Kayexalate enema: 15–50 g plus sorbitol PO or per rectum
7. Dialysis
Hypokalaemia mild
(3.5–2.5 mEq/L)
Diarrhoea,
Laxatives
Hyperaldosteronism
Hyperglycaemia
Potassium depleting
Diuretics
Carbenicillin, sodium penicillin, amphotericin B
Intracellular shift (alkalosis or a rise in pH)
Malnutrition
Weakness
Fatigue
Paralysis
Respiratory difficulty
Constipation
Paralytic ileus
Leg cramps
U waves
T wave flattening
Ventricular arrhythmias
–Pulseless electrical activity (PEA)
Asystole
Gradual correction of hypokalaemia is preferable to rapid correction
Hypokalaemia severe
(<2.5 mEq/L)
1. Maximum IV K replacement should be 10 to 20 mEq/h
2. Infusion of 10 mEq IV over 5 min (if cardiac arrest)
Mg+
Hypermagnesaemia
(>2.2 mEq/L)
Renal failure
Overuse of mg+
Use of laxatives/antacids containing mg+
Areflexia
Muscular weakness
Paralysis
Ataxia
Drowsiness
Confusion
Respiratory failure
Nausea
Vomiting
Hypotension
Hypoventilation
Increased PR and QT
Increased QRS
Decrease P wave voltage
Degree of T wave peaking
Complete AV block
Asystole
1. 10 % solution of calcium chloride (5–10 mL [500–1000 mg] IV)
2. Dialysis
3. Furosemide [1 mEq/kg]
Hypomagnesaemia
(<1.3 mEq/L)
Bowel resection
Pancreatitis
Diarrhoea
Renal disease
Diuretics
Pentamidine
Gentamicin
Digoxin
Alcohol
Hypothermia
Hypercalcaemia
Diabetic ketoacidosis
Hyperthyroidism
Hypothyroidism
Phosphate deficiency
Burns
Sepsis
Seizures
Mental status changes
Dysrhythmias
Vasospasm
Hypokalaemia
Hypocalcaemia
Bronchospasm
Muscle weakness
Prolonged QT and PR intervals
ST segment depression
T wave inversion
Flattening P waves
Widening of QRS
Torsades de pointes
VF
1. 1–2 g IV MgSO4 over 5–60 min
2. For torsades de pointes 1 to 2 g of MgSO4 IV over 5–20 min
Ca++
Hypercalcaemia > 10.5 mEq/L (or > 4.8 mg/dL ionised calcium)
Hyperparathyroidism
Malignancy
Fatigue
Lethargy
Motor weakness
Anorexia
Nausea
Constipation
Abdominal pain
Diuresis
Hallucinations
Disorientation
Hypotonicity
Shortened QT interval
Prolonged PR and QRS intervals
Increased QRS voltage
T wave flattening and widening
Notching of QRS
AV block
1. 0.9 % saline at 300 to 500 mL/h
2. Hemodialysis
3. Chelating agents
4. Furosemide
5. Calcitonin, glucocorticoids
Hypocalcaemia < 8.5 mg/dL (or < 4.2 mg/dL ionised calcium)
Toxic shock
Abnormalities in serum magnesium
Tumour lysis syndrome
Neuromuscular irritability
Carpal-pedal spasm
–Tetany
Laryngospasm
Paraesthesias of the extremities and face
Muscle cramps
Hyperreflexia
Positive Chvostek and Trousseau signs
QT interval prolongation
Terminal T wave inversion
Heart blocks
Ventricular fibrillation
1. 10 % calcium gluconate, 90–180 mg of calcium IV over 10 min
2. IV drip of 540–720 mg of elemental calcium in 500–1000 mL D5W at 0.5–2.0 mg/kg per hour (10–15 mg/kg)
Bibliography
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El-Sherif N, Turitto G. Electrolyte disorders and arrhythmogenesis. Cardiol J. 2011;18:233–45.PubMed
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Task FM, Zipes DP, Camm AJ, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death – executive summary: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Eur Heart J. 2006;27:2099–140.CrossRef
4.
Whalley DW, Wendt DJ, Grant AO. Electrophysiologic effects of acute ischemia and reperfusion and their role in the genesis of cardiac arrhythmias. In: Podrid PJ, Kowey PR, editors. Cardiac arrhythmia: mechanisms, diagnosis, and management. Baltimore: Williams & Wilkins; 1995. p. 109–30.
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Osborn LA, Skipper B, Arellano I, et al. Results of resting and ambulatory electrocardiograms in patients with hypothyroidism and after return to euthyroid status. Heart Dis. 1999;1:8–11.PubMed
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Viskin S, Fish R, Roth A, et al. Clinical problem-solving. QT or not QT? N Engl J Med. 2000;343:352–6.PubMedCrossRef
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