Hypokalemia - Revision history

Danbot: Add reference

2026-03-22T10:06:43Z

Add reference

← Older revision		Revision as of 10:06, 22 March 2026
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	**'''Do NOT start insulin if K <3.3''' — replace K to >3.3 first		**'''Do NOT start insulin if K <3.3''' — replace K to >3.3 first
	*[[Digoxin toxicity]]: maintain K >4.0 mEq/L		*[[Digoxin toxicity]]: maintain K >4.0 mEq/L
	*Refractory hypokalemia: check and replace magnesium; consider amiloride or spironolactone		*Refractory hypokalemia: check and replace magnesium<ref>Huang CL, Kuo E. Mechanism of hypokalemia in magnesium deficiency. J Am Soc Nephrol. 2007;18(10):2649-2652. PMID 17804670</ref>; consider amiloride or spironolactone

	==Disposition==		==Disposition==

Danbot: Strip excess bold

2026-03-22T09:28:04Z

Strip excess bold

← Older revision		Revision as of 09:28, 22 March 2026
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	==Background==		==Background==
	*Serum potassium ~~'''~~<3.5 mEq/L~~'''~~		*Serum potassium <3.5 mEq/L
	*~~'''~~Most common electrolyte abnormality~~'''~~ encountered in clinical practice		*Most common electrolyte abnormality encountered in clinical practice
	*Severity:		*Severity:
	**Mild: 3.0-3.5 mEq/L		**Mild: 3.0-3.5 mEq/L
	**Moderate: 2.5-3.0 mEq/L		**Moderate: 2.5-3.0 mEq/L
	**~~'''~~Severe: <2.5 mEq/L~~'''~~ (risk of arrhythmia, respiratory failure)		**Severe: <2.5 mEq/L (risk of arrhythmia, respiratory failure)
	*~~'''~~Every 1 mEq/L decrease in serum K represents ~200-400 mEq total body deficit~~'''~~		*Every 1 mEq/L decrease in serum K represents ~200-400 mEq total body deficit

	===Causes===		===Causes===
	*~~'''~~Decreased intake~~'''~~: malnutrition, anorexia, alcoholism		*Decreased intake: malnutrition, anorexia, alcoholism
	*~~'''~~GI losses~~'''~~ (most common):		*GI losses (most common):
	**Vomiting (metabolic alkalosis → renal K wasting)		**Vomiting (metabolic alkalosis → renal K wasting)
	**Diarrhea (direct K loss)		**Diarrhea (direct K loss)
	**NG suction, laxative abuse		**NG suction, laxative abuse
	*~~'''~~Renal losses~~'''~~:		*Renal losses:
	**~~'''~~Diuretics~~'''~~ (loops, thiazides — most common medication cause)		**Diuretics (loops, thiazides — most common medication cause)
	**Hyperaldosteronism (primary or secondary)		**Hyperaldosteronism (primary or secondary)
	**[[Renal tubular acidosis]] (types 1 and 2)		**[[Renal tubular acidosis]] (types 1 and 2)
	**Hypomagnesemia (impairs renal K conservation)		**Hypomagnesemia (impairs renal K conservation)
	**Osmotic diuresis ([[DKA]])		**Osmotic diuresis ([[DKA]])
	*~~'''~~Transcellular shift~~'''~~ (K moves into cells):		*Transcellular shift (K moves into cells):
	**~~'''~~Insulin~~'''~~ (therapeutic or endogenous)		**Insulin (therapeutic or endogenous)
	**~~'''~~Beta-2 agonists~~'''~~ (albuterol)		**Beta-2 agonists (albuterol)
	**Alkalosis		**Alkalosis
	**Catecholamine surge, thyrotoxicosis		**Catecholamine surge, thyrotoxicosis
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	==Clinical Features==		==Clinical Features==
	*Often ~~'''~~asymptomatic~~'''~~ with mild hypokalemia		*Often asymptomatic with mild hypokalemia
	*~~'''~~Muscle weakness~~'''~~ (proximal > distal), cramps, myalgia		*Muscle weakness (proximal > distal), cramps, myalgia
	*Ileus, constipation, nausea/vomiting		*Ileus, constipation, nausea/vomiting
	*~~'''~~Rhabdomyolysis~~'''~~ (severe hypokalemia)		*Rhabdomyolysis (severe hypokalemia)
	*~~'''~~Cardiac arrhythmias~~'''~~:		*Cardiac arrhythmias:
	**PACs, PVCs → atrial or ventricular [[tachycardia]] → ~~'''~~torsades de pointes~~'''~~ → VF		**PACs, PVCs → atrial or ventricular [[tachycardia]] → torsades de pointes → VF
	**~~'''~~Potentiates [[digoxin toxicity]]~~'''~~		**Potentiates [[digoxin toxicity]]

	===ECG Changes===		===ECG Changes===
	*~~'''~~Flattened T waves~~'''~~ (earliest)		*Flattened T waves (earliest)
	*~~'''~~Prominent U waves~~'''~~ (after T wave)		*Prominent U waves (after T wave)
	*~~'''~~ST depression~~'''~~		*ST depression
	*Prolonged QT interval		*Prolonged QT interval
	*~~'''~~T-U fusion~~'''~~ (severe)		*T-U fusion (severe)

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Evaluation==		==Evaluation==
	*~~'''~~ECG~~'''~~ (look for U waves, flattened T waves, prolonged QT)		*ECG (look for U waves, flattened T waves, prolonged QT)
	*~~'''~~BMP~~'''~~: K level, bicarbonate (alkalosis?), glucose, creatinine		*BMP: K level, bicarbonate (alkalosis?), glucose, creatinine
	*~~'''~~Magnesium level~~'''~~ (~~'''~~hypokalemia refractory to replacement if Mg not corrected~~'''~~)		*Magnesium level (hypokalemia refractory to replacement if Mg not corrected)
	*~~'''~~Calcium level~~'''~~ (concurrent abnormalities)		*Calcium level (concurrent abnormalities)
	*Consider: urine K (spot urine K/Cr ratio or 24h K), urine chloride, TSH, cortisol/aldosterone if unexplained		*Consider: urine K (spot urine K/Cr ratio or 24h K), urine chloride, TSH, cortisol/aldosterone if unexplained
	*~~'''~~Digoxin level~~'''~~ if on digoxin (hypokalemia increases digoxin sensitivity)		*Digoxin level if on digoxin (hypokalemia increases digoxin sensitivity)

	==Management==		==Management==
	===Guiding Principles===		===Guiding Principles===
	*~~'''~~Always check and replace magnesium first~~'''~~ — hypokalemia is refractory to correction with concurrent hypomagnesemia		*Always check and replace magnesium first — hypokalemia is refractory to correction with concurrent hypomagnesemia
	*Oral replacement preferred when possible (better tolerated, less risky)		*Oral replacement preferred when possible (better tolerated, less risky)
	*IV replacement for severe hypokalemia, ECG changes, or NPO patients		*IV replacement for severe hypokalemia, ECG changes, or NPO patients

	===Mild Hypokalemia (3.0-3.5 mEq/L)===		===Mild Hypokalemia (3.0-3.5 mEq/L)===
	*~~'''~~Oral KCl 20-40 mEq PO~~'''~~ q2-4h (typical total dose 40-100 mEq/day)		*Oral KCl 20-40 mEq PO q2-4h (typical total dose 40-100 mEq/day)
	*Increase dietary potassium		*Increase dietary potassium

	===Moderate Hypokalemia (2.5-3.0 mEq/L)===		===Moderate Hypokalemia (2.5-3.0 mEq/L)===
	*~~'''~~KCl 10-20 mEq/hr IV~~'''~~ via peripheral line (max ~~'''~~40 mEq/L concentration~~'''~~ peripherally)		*KCl 10-20 mEq/hr IV via peripheral line (max 40 mEq/L concentration peripherally)
	**Higher concentrations require ~~'''~~central line~~'''~~		**Higher concentrations require central line
	*~~'''~~Max infusion rate: 10-20 mEq/hr~~'''~~ (peripheral); up to ~~'''~~40 mEq/hr~~'''~~ via central line with cardiac monitoring		*Max infusion rate: 10-20 mEq/hr (peripheral); up to 40 mEq/hr via central line with cardiac monitoring
	*Concurrent oral supplementation		*Concurrent oral supplementation

	===Severe Hypokalemia (<2.5 mEq/L or ECG Changes)===		===Severe Hypokalemia (<2.5 mEq/L or ECG Changes)===
	*~~'''~~Continuous cardiac monitoring~~'''~~		*Continuous cardiac monitoring
	*~~'''~~KCl 20-40 mEq/hr IV via central line~~'''~~		*KCl 20-40 mEq/hr IV via central line
	*~~'''~~Magnesium sulfate 2g IV~~'''~~ (if Mg not checked yet, give empirically)		*Magnesium sulfate 2g IV (if Mg not checked yet, give empirically)
	*Recheck K every 1-2 hours		*Recheck K every 1-2 hours
	*May require ~~'''~~200+ mEq total replacement~~'''~~		*May require 200+ mEq total replacement

	===Special Situations===		===Special Situations===
	*~~'''~~[[DKA]]~~'''~~: K may be normal or elevated on presentation but total body stores are depleted		*[[DKA]]: K may be normal or elevated on presentation but total body stores are depleted
	**Replace K ''before or concurrent with insulin'' when K <5.3		**Replace K ''before or concurrent with insulin'' when K <5.3
	**'''Do NOT start insulin if K <3.3''' — replace K to >3.3 first		**'''Do NOT start insulin if K <3.3''' — replace K to >3.3 first
	*~~'''~~[[Digoxin toxicity]]~~'''~~: maintain K >4.0 mEq/L		*[[Digoxin toxicity]]: maintain K >4.0 mEq/L
	*~~'''~~Refractory hypokalemia~~'''~~: check and replace magnesium; consider amiloride or spironolactone		*Refractory hypokalemia: check and replace magnesium; consider amiloride or spironolactone

	==Disposition==		==Disposition==
	*~~'''~~Admit~~'''~~ if K <2.5, symptomatic, ECG changes, arrhythmia, or ongoing losses		*Admit if K <2.5, symptomatic, ECG changes, arrhythmia, or ongoing losses
	*~~'''~~Continuous telemetry~~'''~~ for K <3.0 or ECG changes		*Continuous telemetry for K <3.0 or ECG changes
	*~~'''~~Discharge~~'''~~ if mild (3.0-3.5), asymptomatic, clear correctable cause, tolerated PO replacement, normal ECG		*Discharge if mild (3.0-3.5), asymptomatic, clear correctable cause, tolerated PO replacement, normal ECG
	*Close follow-up with recheck in 24-48 hours		*Close follow-up with recheck in 24-48 hours

Danbot: Major update: severity-based replacement protocol, IV rates/concentrations, magnesium correction requirement, DKA K thresholds, ECG changes, digoxin interaction, references with PMIDs

2026-03-21T19:48:00Z

Major update: severity-based replacement protocol, IV rates/concentrations, magnesium correction requirement, DKA K thresholds, ECG changes, digoxin interaction, references with PMIDs

Show changes

Danbot: Add MedicationDose entries (potassium chloride PO/IV) with SMW annotations

2026-03-20T18:40:41Z

Add MedicationDose entries (potassium chloride PO/IV) with SMW annotations

← Older revision		Revision as of 18:40, 20 March 2026
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	**However, more recent studies suggest 3.5 - 4.5 mEq/L results in the lowest mortality		**However, more recent studies suggest 3.5 - 4.5 mEq/L results in the lowest mortality



			==Medication Dosing==
			{{MedicationDose
			\| drug = Potassium chloride
			\| dose = 20mEq q3hr or 40mEq q6hr
			\| route = PO
			\| context = Oral repletion (preferred); every 10mEq raises serum K ~0.1mEq/L
			\| indication = Hypokalemia
			\| population = Adult
			}}
			{{MedicationDose
			\| drug = Potassium chloride
			\| dose = 10mEq/hr (max 20mEq/hr via central line)
			\| route = IV
			\| context = Symptomatic or K <2.5; give in dilute solution
			\| indication = Hypokalemia
			\| population = Adult
			\| notes = Do not replete with dextrose-containing solutions; continuous telemetry recommended
			}}

	==Disposition==		==Disposition==

Imogen: Add glycyrrhizin

2025-08-06T03:09:39Z

Add glycyrrhizin

← Older revision		Revision as of 03:09, 6 August 2025
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	*Barium		*Barium
	*Catecholamines		*Catecholamines
			*Glycyrrhizin (licorice extract)
	*[[Insulin]]		*[[Insulin]]
	*L-dopa		*L-dopa

Imogen: /* Drugs */ alphabetize

2025-08-06T03:06:49Z

Drugs: alphabetize

← Older revision		Revision as of 03:06, 6 August 2025
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	===Drugs===		===Drugs===
			*Barium
			*Catecholamines
			*[[Insulin]]
			*L-dopa
			*[[Lithium toxicity\|Lithium]]
	*[[Penicillins]]		*[[Penicillins]]
	*[[Lithium toxicity\|Lithium]]
	*L-dopa
	*[[Theophylline]], methylxanthines (e.g. [[caffeine]]
	*[[Insulin]]
	*Barium
	*[[Quinine]]		*[[Quinine]]
	*~~Catecholamines~~		*[[Theophylline]], methylxanthines (e.g. [[caffeine]])

	===Other===		===Other===

Patricklin at 01:28, 23 May 2024

2024-05-23T01:28:42Z

← Older revision		Revision as of 01:28, 23 May 2024
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	==Background==		==Background==
			*Hypokalemia is one of the most common electrolyte derangements
			*While mild-moderate hypokalemia can be asymptomatic or mildly symptomatic, severe hypokalemia can be fatal
			*Potassium is predominantly intracellular; important in maintaining cell membrane potential, especially in cardiac/nerve/muscle tissue
			*While the renal and endocrine systems regulate total body potassium, transient physiologic shifts can greatly alter measured serum potassium

	==Clinical Features==		==Clinical Features==
	*Central nervous system		*Central nervous system
	**[[Weakness]]		**[[Weakness]] or [[Numbness]]
	**[[myalgia\|Cramps]]		**[[myalgia\|Cramps]]
	**Hyporeflexia		**Hyporeflexia
	*Gastrointestinal		*Gastrointestinal
	**[[Ileus]]		**[[Ileus]]
			**[[Nausea and vomiting]]
	*Renal		*Renal
	**[[Metabolic alkalosis]]		**[[Metabolic alkalosis]]
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	**[[PACs]]/[[PVCs]]		**[[PACs]]/[[PVCs]]
	**[[ACLS: Bradycardia\|Bradycardia]] or [[atrial tachycardia\|atrial]]/[[junctional tachycardia]]		**[[ACLS: Bradycardia\|Bradycardia]] or [[atrial tachycardia\|atrial]]/[[junctional tachycardia]]
			**[[Atrial fibrillation]]
	**[[AV block]]		**[[AV block]]
	**[[Tachycardia (wide)\|Ventricular tachycardia]], [[Adult pulseless arrest\|Ventricular fibrillation]]		**[[Tachycardia (wide)\|Ventricular tachycardia]], [[Adult pulseless arrest\|Ventricular fibrillation]]


	==Differential Diagnosis<ref>In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill; Accessed November 29, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109381281</ref>==		==Differential Diagnosis<ref>In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill; Accessed November 29, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109381281</ref>==
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	**[[Vomiting]], [[diarrhea]], fistula		**[[Vomiting]], [[diarrhea]], fistula
	*Renal		*Renal
	**[[Diuretics]]		**[[Diuretics]], especially loop and thiazide diuretics
	**Osmotic diuresis (late-presenting [[Diabetic ketoacidosis\|DKA]])		**Osmotic diuresis (late-presenting [[Diabetic ketoacidosis\|DKA]])
	**Hyperaldosteronism		**Hyperaldosteronism
			**[[Renal tubular acidosis]]
	**[[Hypercalcemia]]		**[[Hypercalcemia]]
	**[[Hypomagnesemia]]		**[[Hypomagnesemia]]
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	*Serum potassium level is diagnostic		*Serum potassium level is diagnostic
	**Normal = 3.5-5meq/L		**Normal = 3.5-5meq/L
	**Severe hypokalemia = <2.5meq/L		**Moderate hypokalemia = between 2.5 and 3.0 meq/L. Severe hypokalemia = <2.5meq/L
	*Always check magnesium		*Always check magnesium
	**Na+/K+ ATPase pump requires Mg to function, therefore low Mg can lead to refractory hypoK		**Na+/K+ ATPase pump requires Mg to function, therefore low Mg can lead to refractory hypoK
	*~~Suggestive~~ [[ECG]] findings:		*Obtain [[ECG]]. Suggestive findings include:
	**[[ST segment depression]]		**[[ST segment depression]] or flattened or inverted [[T wave]]
	**U wave (V4-V6)		**U wave (V4-V6)
	**[[QT prolongation]]		**[[QT prolongation]]
	**[[Premature ventricular contraction]]		**[[Premature ventricular contraction]], other ectopy, or any new arrhythmia
			*Careful review of medication list


	[[Image:ECG Hypokalemia.jpg]]		[[Image:ECG Hypokalemia.jpg]]
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	*Potassium repletion (PO or IV)		*Potassium repletion (PO or IV)
	**Every 10mEq KCl → serum K ↑ ~0.1mEq/L		**Every 10mEq KCl → serum K ↑ ~0.1mEq/L
	**PO preferred (if symptomatic or level is <2.5, both oral and IV should be given)		**PO preferred; if symptomatic or level is <2.5, both oral and IV should be given
			**Note: Administration of KCl during an ongoing intracellular shift can lead to rebound hyperkalemia when the shift reverses
			**Potassium chloride is usually preferred; other forms of potassium salts (potassium bicarbonate, potassium phosphate) increases serum potassium slower<ref>Cohn JN, Kowey PR, Whelton PK, Prisant LM. New guidelines for potassium replacement in clinical practice: a contemporary review by the National Council on Potassium in Clinical Practice. Arch Intern Med. 2000 Sep 11;160(16):2429-36. doi: 10.1001/archinte.160.16.2429. PMID: 10979053.</ref>
			**Consider repeating chem panel 3-4 hrs later to check for response; check faster if giving at a faster rate
	*Oral potassium		*Oral potassium
	**Inexpensive and rapidly absorbed		**Inexpensive, well-tolerated, and rapidly absorbed
			**Consider giving 20 mEq q3hr or 40 mEq PO q6hr
	**KCl tablet (elixir form available but has poor taste)		**KCl tablet (elixir form available but has poor taste)
	**K-Dur (extended release tablet) is large and may be difficult to swallow		**K-Dur (extended release tablet) is large and may be difficult to swallow
	**If sending patient home can also increase food intake of potassium as an alternative or supplementing potassium tablets. Printable table that can be given to the patient available at this reference: <ref>[https://www.mayoclinic.org/drugs-supplements/potassium-supplement-oral-route-parenteral-route/description/drg-20070753?p=1 Potassium Supplement (Oral Route, Parenteral Route) from Mayo Clinic]</ref>.		**If sending patient home can also increase food intake of potassium as an alternative or supplementing potassium tablets. Printable table that can be given to the patient available at this reference: <ref>[https://www.mayoclinic.org/drugs-supplements/potassium-supplement-oral-route-parenteral-route/description/drg-20070753?p=1 Potassium Supplement (Oral Route, Parenteral Route) from Mayo Clinic]</ref>.
	*Intravenous potassium		*Intravenous potassium
	**Must be given in dilute solutions at slow rate (~~10meq~~/hour) to minimize side effects and cardiac toxicity		**Must be given in dilute solutions at slow rate (10 mEq/hour) to minimize side effects (burning/phlebitis) and cardiac toxicity
	**~~Generally should not give more than 40mEq~~ via IV		***If needing to infuse at 20 mEq/hr, consider infusion via central line or two peripheral lines
	**~~Side effects: Local tissue burning~~, ~~phlebitis~~, ~~sclerosis~~		**Consider runs of 10 mEq in 100 mL of water, each administered over 1 hr. Or 40-60 mEq in a 1000 mL bag, administered at a rate appropriate to type of IV access
			**Do not replete with dextrose-containing solutions since dextrose-induced insulin release can worsen hypokalemia
			**Continuous tele is recommended for both the underlying hypokalemia and the potassium administration
	*Also treat [[Hypomagnesemia]] if present		*Also treat [[Hypomagnesemia]] if present
	*Re-check ECG after treatment <ref>Slovis, Corey. "Electrolyte Emergencies". Presentation.</ref>		*Re-check ECG after treatment <ref>Slovis, Corey. "Electrolyte Emergencies". Presentation.</ref>
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	**Previous studies and many professional organizations recommend maintaining K between 4.0 - 5.0 mEq/L in MI patients		**Previous studies and many professional organizations recommend maintaining K between 4.0 - 5.0 mEq/L in MI patients
	**However, more recent studies suggest 3.5 - 4.5 mEq/L results in the lowest mortality		**However, more recent studies suggest 3.5 - 4.5 mEq/L results in the lowest mortality


	==Disposition==		==Disposition==

Elcatracho: /* Evaluation */

2021-02-10T15:57:16Z

Evaluation

← Older revision		Revision as of 15:57, 10 February 2021
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	**Severe hypokalemia = <2.5meq/L		**Severe hypokalemia = <2.5meq/L
	*Always check magnesium		*Always check magnesium
			**Na+/K+ ATPase pump requires Mg to function, therefore low Mg can lead to refractory hypoK
	*Suggestive [[ECG]] findings:		*Suggestive [[ECG]] findings:
	**[[ST segment depression]]		**[[ST segment depression]]
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	[[Image:ECG Hypokalemia.jpg]]		[[Image:ECG Hypokalemia.jpg]]


	==Management==		==Management==

Elcatracho: /* Increased loss */

2020-11-29T18:32:17Z

Increased loss

← Older revision		Revision as of 18:32, 29 November 2020
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	*Renal		*Renal
	**[[Diuretics]]		**[[Diuretics]]
	**Osmotic diuresis ([[Diabetic ketoacidosis\|DKA]])		**Osmotic diuresis (late-presenting [[Diabetic ketoacidosis\|DKA]])
	**Hyperaldosteronism		**Hyperaldosteronism
	**[[Hypercalcemia]]		**[[Hypercalcemia]]

Elcatracho: /* Differential DiagnosisIn: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill; Accessed November 29, 2020. https://accessmedicine.mhmedical.com/cont...

2020-11-29T18:31:28Z

/* Differential DiagnosisIn: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill; Accessed November 29, 2020. https://accessmedicine.mhmedical.com/cont...

← Older revision		Revision as of 18:31, 29 November 2020
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	*[[Quinine]]		*[[Quinine]]
	*Catecholamines		*Catecholamines

			===Other===
			*Acute leukemia and lymphomas
			*Recovery from megaloblastic anemia
			*Hypothermia (accidental or induced)

	==Evaluation==		==Evaluation==