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

Potassium Chloride

CategoryDetails
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 injection dose is ~100+ mEq undiluted as IV push x 1-3
  o Being replaced to sedatives due to issues with efficacy and ethical issues

Evidence

Overview of 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 boluses		s/p KCl, the rhythm changed to sinus rhythm
Pt discharged home on a regular rehabilitation program
Liu, 2020Case reportCase: 21 yr old with PMHx hyperthyroidism with thyrotoxic and K+ 1.5 mEq/L
IV bolus KCl 40 mEq/40 mL via the central		ROSC 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 line		Less 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/L
IV KCl 40 mEq via central line		Immediate reversal of asystole and a return to sinus rhythm.
She had full recovery with no residual neurological deficit
AHA ACLS Guidelines“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

References

  • Abdulaziz S, Dabbagh O, Al Daker MO, Hassan I. Hypokalaemia and refractory asystole complicating diabetic ketoacidosis, lessons for prevention. BMJ Case Rep. 2012;2012. PMID: 23220438.
  • Bannister B, Ginsburg R, Shneerson J. Cardiac arrest due to liquorice-induced hypokalaemia. Br Med J. 1977;2(6089):738-9. PMID: 912278.
  • Elmahrouk AF, Elghaysha E, Arafat AA, Edrees A, Aluthman U, Jamjoom AA. Bolus potassium in frustrated ventricular fibrillation storm. J Card Surg. 2020;35(2):480-481. PMID: 31765017.
  • Jouffroy R, Lamhaut L, Philippe P, An K, Carli P, Vivien B. A new approach for treatment of refractory ventricular fibrillation allowed by extra corporeal life support (ECLS)? Resuscitation. 2014;85(8):e118. PMID: 24810737.
  • Palatinus JA, Lieber SB, Joyce KE, Richards JB. 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.
  • 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.
  • 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.
  • Liu JK, Sim SS, Hsieh FC, Wu YH. Intravenous potassium solution boluses save a life from hypokalemic cardiac arrest. Am J Emerg Med. 2020;38(1):162.e1-162.e2. PMID: 31422859.
  • Zimmers TA, Sheldon J, Lubarsky DA, López-Muñoz F, Waterman L, Weisman R, Koniaris LG. Lethal injection for execution: chemical asphyxiation? PLoS Med. 2007;4(4):e156. PMID: 17455994.
  • Alfonzo AV, Isles C, Geddes C, Deighan C. Potassium disorders--clinical spectrum and emergency management. Resuscitation. 2006;70(1):10-25. PMID: 16600469.
Tags:hypokalemia cardiac arrest potassium reversible causes