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An 18 month old with history of pseudohypoaldosteronism presents with a K+ level of 9.0 and peaked T waves with mild QRS widening on the electrocardiogram, and blood pressure of 70/40.
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July 14, 2020 at 10:14 pm
E) 10% Calcium chloride 0.2 mL/kg (20 mg/kg) IV
Calcium therapy is first-line treatment for significant hyperkalemia because stabilizing the cardiac membrane is prioritized. Because the patient has severe hyperkalemia with significant electrocardiogram findings including widening of the QRS and hemodynamic compromise with BP 70/40, calcium chloride, which results in a more rapid increase in serum ionized calcium than calcium gluconate. (The tradeoff is the calcium gluconate is less irritating to the veins). Other measures to shift K+ intracellularly include insulin + glucose, beta-adrenergic antagonists such as albuterol nebulized, and sodium bicarbonate, but calcium should be first-line therapy in this case. Sodium polystyrene sulfonate (kayexalate) orally or rectally uses cation exchange to remove excess potassium from the body, but this therapy does not have a role in emergent management. Pseudohypoaldosteronism, a rare inherited disease causing abnormal mineralocorticoid receptor activity, manifests as salt wasting, hyperkalemia, metabolic acidosis, with high measured levels of aldosterone.