The Clinical Problem Solvers Episode 448 – RLR – Hyperkalemia
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Mar 1, 2026 A dramatic ED case where a critical potassium of 7.9 triggers rapid decision making and team coordination. They debate bedside assessment versus ordering lifesaving therapies first. Practical steps for stabilizing severe hyperkalemia and sequencing treatments are reviewed. The diagnostic twist involves a swollen, painful knee leading to arthrocentesis and a final diagnosis of gout.
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Lab Result Interrupts Knee Aspiration
- Anecdote: Robbie was performing a knee arthrocentesis when a nurse interrupted with a point‑of‑care potassium of 7.9.
- He excused himself, prioritized the hyperkalemia, and later returned to manage the knee once safe.
Immediate Steps For Severe Hyperkalemia
- Do treat a potassium ≥6 as potentially life‑threatening and repeat the test while preparing immediate interventions.
- Recheck potassium, send AST to detect hemolysis, give calcium gluconate, get ECG and place patient on telemetry promptly.
Kidney Function Makes Hyperkalemia Plausible
- Insight: Significant hyperkalemia with a normal creatinine is unlikely unless there's an overwhelming source like tumor lysis.
- A potassium of 7.9 is far more believable when creatinine is 9, pointing to renal failure as the main cause.