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Introduction

  • Severe hypokalemia may precipitate profound and life-threatening cardiac complications including ventricular tachycardia and asystole.
  • Classical teaching is that in cardiac arrest with non-shockable rhythms the management include to identify and treat the H’s & T’s which include hyper and less commonly hypokalemia.
  • Potassium chloride is the therapy of choice, however, the dose and administration of potassium during cardiac arrest is controversial and limited to case series and case reports.

Clinical Detail

AttributePotassium Chloride
Dose10–20 mEq initial dose followed by institutional protocol
AdministrationAdminister at 2 mEq/min followed by another 10 mEq IV over 5–10 mins
PK/PDOnset immediate; increase in serum potassium is variable; renal excretion 85–90%; removed by dialysis
CommentCompatible with magnesium sulfate, calcium chloride, epinephrine, amiodarone, lidocaine, and vasopressin; lethal dose is ~100+ mEq undiluted as IV push x 1–3 (being replaced to sedatives due to issues with efficacy and ethical issues)

Evidence

Author, YearDesign / Sample SizeCase & InterventionOutcome
Elmahrouk, 2020Case report46-year-old post CABG with malignant ventricular arrhythmia on ECMO and intra-aortic balloon pump s/p various antiarrhythmic medications. IV KCl 20 mEq bolusess/p KCl, the rhythm changed to sinus rhythm. Pt discharged home on a regular rehabilitation program
Liu, 2020Case report21 yr old with PMHx hyperthyroidism with thyrotoxic and K+ 1.5 mEq/dL. IV bolus KCl 40 mEq/40 mL via the centralROSC with stable hemodynamic status at 8 minutes post KCl after 31 total minutes of CPR. Pt was extubated on the next day and was discharged without any complication after a total of 5 hospital days
Jouffroy, 2014Case report50-year-old male with refractory ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA) s/p ECMO, 20 shocks, and various antiarrhythmic medications. IV KCl 40 mEq via central lineLess than 1 min later, the patient had sinus cardiac rhythm, and progressively recovered circulatory function. Patient was discharged on day 11 with a cerebral performance category score of 2
Abdulaziz, 2012Case report23-year-old woman presenting in DKA and cardiac with K+ 1.7 mEq/dL. IV KCl 40 mEq via central lineImmediate reversal of asystole and a return to sinus rhythm. She had full recovery with no residual neurological deficit
AHA ACLS GuidelinesGuideline statement“If cardiac arrest from hypokalemia is imminent (ie, malignant ventricular arrhythmias), rapid replacement of potassium is required.”Give an initial infusion of 2 mEq/min, followed by another 10 mEq IV over 5 to 10 minutes

Conclusions

    Compatible with magnesium sulfate,

    calcium chloride, epinephrine,

    amiodarone, lidocaine, and

    vasopressin

    Lethal infection dose is ~100+ mEq

    undiluted as IV push x 1-3

    o Being replaced to sedatives

    due to issues with efficacy

    and ethical issues

References

  1. Abdulaziz S, Dabbagh O, Al Daker MO, et al. Hypokalaemia and refractory asystole complicating diabetic ketoacidosis, lessons for prevention. BMJ Case Rep. 2012;2012():. PMID 23220438.
  2. Bannister B, Ginsburg R, Shneerson J. Cardiac arrest due to liquoriceinduced hypokalaemia. Br Med J. 1977;2(6089):738-9. PMID 912278.
  3. Elmahrouk AF, Elghaysha E, Arafat AA, et al. Bolus potassium in frustrated ventricular fibrillation storm. J Card Surg. 2020;35(2):480-481. PMID 31765017.
  4. Jouffroy R, Lamhaut L, Philippe P, et al. A new approach for treatment of refractory ventricular fibrillation allowed by extra corporeal life support (ECLS)? Resuscitation. 2014;85(8):e118. PMID 24810737.
  5. Palatinus JA, Lieber SB, Joyce KE, et al. Extracorporeal Membrane Oxygenation Support for Hypokalemia-induced Cardiac Arrest: A Case Report and Review of the Literature. J Emerg Med. 2015;49(2):159-64. PMID 26004853.
  6. Philips DA, Bauch TD. Rapid correction of hypokalemia in a patient with an implantable cardioverter-defibrillator and recurrent ventricular tachycardia. J Emerg Med. 2010;38(3):308-16. PMID 18375090.
  7. Tassone H, Moulin A, Henderson SO. The pitfalls of potassium replacement in thyrotoxic periodic paralysis: a case report and review of the literature. J Emerg Med. 2004;26(2):157-61. PMID 14980336.
  8. Liu JK, Sim SS, Hsieh FC, et al. Intravenous potassium solution boluses save a life from hypokalemic cardiac arrest. Am J Emerg Med. 2020;38(1):162.e1-162.e2. PMID 31422859.
  9. Zimmers TA, Sheldon J, Lubarsky DA, et al. Lethal injection for execution: chemical asphyxiation? PLoS Med. 2007;4(4):e156. PMID 17455994.
  10. Alfonzo AV, Isles C, Geddes C, et al. Potassium disorders–clinical spectrum and emergency management. Resuscitation. 2006;70(1):10-25. PMID 16600469.
Tags:hypokalemia cardiac arrest potassium reversible causes

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