A patient in ICU develops acute hyperkalemia with serum K^+ = 7.1 text mEq/L and ECG changes (peaked T waves, wide QRS, sine wave pattern). What is the FIRST and MOST critical intervention?

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Nursing QUESTION #9250

Question 1

A patient in ICU develops acute hyperkalemia with serum K\(^+ = 7.1 \text{ mEq/L}\) and ECG changes (peaked T waves, wide QRS, sine wave pattern). What is the FIRST and MOST critical intervention?

Administer Sodium Bicarbonate IV to shift K\(^+\) intracellularly
Administer IV Calcium Gluconate or Calcium Chloride to stabilize the myocardium✔️
Start Kayexalate (sodium polystyrene sulfonate) to eliminate K\(^+\) from the gut
Start emergent hemodialysis to remove excess K\(^+\)

Correct Answer Explanation

Correct Answer: B — IV Calcium (Gluconate or Chloride) — cardiac membrane stabilization

Management of Acute Severe Hyperkalemia — Stepwise Approach:

Step	Drug/Intervention	Onset	Mechanism
1 (First priority)	IV Calcium Gluconate 10% (10 mL) or Calcium Chloride	1–3 min	Stabilizes cardiac membrane (does NOT lower K\(^+\))
2	IV Insulin + Dextrose (10 units regular insulin + 50 mL D50%)	15–30 min	Shifts K\(^+\) intracellularly
3	Salbutamol nebulization (10–20 mg)	15–30 min	Shifts K\(^+\) intracellularly via \(\beta_2\) stimulation
4	Sodium Bicarbonate (if acidotic)	30–60 min	Shifts K\(^+\) intracellularly
5	Kayexalate / Patiromer	Hours	GI elimination of K\(^+\)
6	Hemodialysis	Immediate	Definitive removal — for refractory cases

Calcium is given FIRST because it prevents fatal arrhythmias immediately — it stabilizes the myocardial membrane without changing K\(^+\) levels.

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