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Lesson

Hyperkalemia on the Monitor

12 min Cardiac & ECG

Objective: Spot the hyperK ECG progression, treat it as a membrane emergency when the strip fits, and remember calcium does not lower the potassium — it buys a safer QRS.

Why This Is Hard

You do not get a potassium on most trucks. You get a dialysis patient who missed Tuesday, a crushed leg, an ACE-inhibitor plus a potassium-sparing diuretic, or a wide, slow, ugly strip that looks like VT and is not. AHA 2025 special-circumstances teaching still lists hyperkalemia among the Hs and Ts. The ECG can lag or lie — absence of peaked T waves does not rule hyperK out — but when the progression is there, treat the membrane.

Say out loud
  • Missed dialysis / crush / ACE+K-sparing / wide-slow-ugly
  • Peaked T → flat P → wide QRS → sine wave
  • Calcium for ECG toxicity — it does not lower K+
  • Wide-complex “VT” in a dialysis patient may be hyperK, not a lidocaine problem

ECG Progression (Teaching)

  • Tall, peaked, symmetric T waves (often the earliest clue).
  • PR lengthening, P waves flatten and disappear.
  • QRS widens, conduction blocks, bradycardia, sine-wave ventricular rhythm, then VF or asystole/PEA.

LITFL-style teaching: the T is “pulled up,” stretching the rest of the tracing. Do not require a perfect textbook peaked T before you think hyperK in the right patient.

Field Treatment Framing (Not a Formulary)

  • Calcium (gluconate or chloride per protocol) antagonizes cardiac membrane effects. It does not lower serum K. Repeat per protocol if the QRS stays wide. Watch the strip — narrowing is the win.
  • Shift: albuterol (nebulized, often high-dose in hyperK protocols), insulin/glucose where authorized. These hide K inside cells for a while.
  • Remove / prevent: you are not running dialysis in the truck. Destination, stop further potassium (do not hang K-containing fluids in crush — see crush).
  • Sodium bicarbonate is not a universal hyperK drug. Follow protocol; it is not a substitute for calcium when the QRS is a sine wave.

Arrest

Wide, slow PEA in a dialysis or crush patient is hyperK until you have a better story. CPR, calcium per protocol, and the rest of the Hs/Ts. Do not treat it as ordinary VT with an antiarrhythmic first (see WCT mimics and amiodarone/lidocaine).

Field Pitfalls

  • Shocking a sine wave forever without giving calcium.
  • Calling peaked T waves “hyperacute STEMI” without a territorial story — still transmit; do not skip ACS thinking, but hold both ideas.
  • Waiting for a hospital lab to treat a sine-wave tracing.

Practice

60-second drill

Partner describes: missed dialysis, HR 36, QRS looks like a blob. Say calcium vs amiodarone vs “just pace it” in one sentence, then name one shift therapy your protocol might include.

Related: PEA, Albuterol, Crush Syndrome.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.

1. A teaching ECG progression of hyperkalemia is:
2. IV calcium in this context:
3. Wide, slow, ugly PEA in a missed-dialysis patient should make you think:
4. A normal ECG in a high-risk patient:
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