Hyperkalemia: The Daily PANCE Blueprint
A 60-year-old man with end-stage renal disease on hemodialysis missed his last two sessions and presents with weakness and palpitations. His potassium is 7.2 mEq/L. His ECG shows tall, peaked T waves, a widening QRS, and flattened P waves. He is awake but says he feels "funny." Which of the following is the most appropriate first step in management?
A. Regular insulin with intravenous dextrose
B. Intravenous calcium gluconate
C. Sodium polystyrene sulfonate (oral)
D. Nebulized albuterol
E. Arrange urgent hemodialysis
Answer and topic summary
The answer is B. Intravenous calcium gluconate
A potassium of 7.2 with peaked T waves, a widening QRS, and flattening P waves is severe hyperkalemia with ECG changes — a rhythm emergency. The very first move is IV calcium (gluconate or chloride): it does not lower the potassium, but it stabilizes the cardiac membrane within minutes and buys time, preventing the slide into a sine-wave rhythm and arrest. That is the trap — insulin plus dextrose, albuterol, and dialysis all genuinely lower potassium (shift or remove it), but they act too slowly to protect the heart in the first moments, so calcium comes first. Give calcium, then shift with insulin/dextrose and albuterol, then remove with dialysis or a binder (potassium binders such as patiromer have largely replaced the slow, risky sodium polystyrene).
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