A patient with hyperkalemia and ECG changes. What is the immediate management?

• A. Administer calcium gluconate to stabilize myocardium, then shift K+ intracellularly with insulin plus glucose and remove K+
• B. Administer bicarbonate only
• C. Administer insulin alone
• D. Administer potassium-sparing diuretics

Answer: (A)

When potassium is high and the ECG shows dangerous changes, the priority is to protect the heart first and then lower the potassium quickly. IV calcium gluconate stabilizes cardiac cell membranes, which reduces the risk of life-threatening arrhythmias even though it doesn’t lower the potassium level itself. After the myocardium is stabilized, shift potassium into cells by giving insulin with glucose; insulin drives potassium into cells via the sodium–potassium pump, and glucose is given to prevent hypoglycemia. Finally, remove potassium from the body through renal excretion with diuretics if kidney function allows, or by dialysis in severe cases, and/or using potassium-binding therapies. Bicarbonate alone is less reliable for rapid correction, insulin without glucose can cause dangerous hypoglycemia, and potassium-sparing diuretics would worsen hyperkalemia.