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Severe hyperkalemia with ECG changes — ABIM Board MCQ

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HardNephrologySevere hyperkalemia with ECG changesABIM Board

A 70-year-old taking lisinopril and spironolactone has weakness, potassium 7.1 mEq/L, bicarbonate 17 mEq/L and QRS widening. Which sequence is required immediately?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Give IV calcium and insulin with dextrose, then remove potassium

ECG-toxic hyperkalemia first requires membrane stabilization with IV calcium, followed by rapid shifting and potassium elimination. Resins or diuretics alone are too slow, bicarbonate alone is inadequate, and outpatient management is unsafe with conduction abnormalities.

Reference: KDIGO Controversies Conference: acute hyperkalemia in the emergency department: https://pubmed.ncbi.nlm.nih.gov/31064689/