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Hyperkalemia in Cardiac Arrest
Question# 940
Question about the hyperkalemia medical directive! I recently had a VSA patient who was initially Asystole, but went into a wide complex PEA at around 50 after Epi x2. Patient had No comorbidities such as Dialysis or end stage renal disease, but they were taking Potassium sparring diuretic Spironolactone. Would a patch to BHP be warranted in this situation for Calcium and Salbutamol administration? Is there any evidence supporting use of this directive for a patient that may present as above?
Answer:
As a general principle the RPPEO supports paramedics calling OMC to discuss the care of any patient where the paramedic feels there may be ambiguity in the medical directive or there may be an opportunity to optimize management.
In terms of the management of hyperkalemia in cardiac arrest there are a few things to consider.
Even in patients where hyperkalemia is the suspected cause of cardiac arrest the newest 2025 resuscitation guidelines make the following Class 2b (Weak) recommendation: "The effectiveness of IV calcium administration for adults and children in cardiac arrest from suspected hyperkalemia is not well established."
Part 10: Adult and Pediatric Special Circumstances on Resuscitation: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001380
Additionally, the routine administration of calcium (chloride or gluconate) in cardiac arrest is not recommended. There was a landmark 2021 RCT of Calcium vs Saline in PEA cardiac arrest which was stopped early for safety because the calcium group's outcomes were so much worse than the saline group that it was unethical to continue. This study combined some more recent retrospective reviews of PEA cardiac arrest suggest a trend towards harm associated with the routine use of calcium in cardiac arrest, even in wide complex PEA arrests.
Source:
Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest: a randomized clinical trial. JAMA. 2021;326(22):2268-2276. doi:10.1001/jama.2021.20929 [jamanetwork.com]
You correctly identified that spironolactone is a potassium sparing diuretic and that patients on it are at an objectively higher risk for hyperkalemia so using calcium in this patient would not be strictly routine but our threshold for the use of calcium may need to be a little higher given the possible risks of harm associated with it. The patients we should be selecting for the use of calcium in cardiac arrest are really ones that have a strong likelihood of profound hyperkalemia that was a contributing factor to their cardiac arrest and not just the patients that may happen to be hyperkalemic and also in cardiac arrest. Really we should be looking at the patients that have true end-stage renal disease, are on dialysis, or were in a rhythm consistent with severe hyperkalemia prior to cardiac arrest. This aligns with the indications listed in the medical directive.
In terms of the management of hyperkalemia in cardiac arrest there are a few things to consider.
Even in patients where hyperkalemia is the suspected cause of cardiac arrest the newest 2025 resuscitation guidelines make the following Class 2b (Weak) recommendation: "The effectiveness of IV calcium administration for adults and children in cardiac arrest from suspected hyperkalemia is not well established."
Part 10: Adult and Pediatric Special Circumstances on Resuscitation: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001380
Additionally, the routine administration of calcium (chloride or gluconate) in cardiac arrest is not recommended. There was a landmark 2021 RCT of Calcium vs Saline in PEA cardiac arrest which was stopped early for safety because the calcium group's outcomes were so much worse than the saline group that it was unethical to continue. This study combined some more recent retrospective reviews of PEA cardiac arrest suggest a trend towards harm associated with the routine use of calcium in cardiac arrest, even in wide complex PEA arrests.
Source:
Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest: a randomized clinical trial. JAMA. 2021;326(22):2268-2276. doi:10.1001/jama.2021.20929 [jamanetwork.com]
You correctly identified that spironolactone is a potassium sparing diuretic and that patients on it are at an objectively higher risk for hyperkalemia so using calcium in this patient would not be strictly routine but our threshold for the use of calcium may need to be a little higher given the possible risks of harm associated with it. The patients we should be selecting for the use of calcium in cardiac arrest are really ones that have a strong likelihood of profound hyperkalemia that was a contributing factor to their cardiac arrest and not just the patients that may happen to be hyperkalemic and also in cardiac arrest. Really we should be looking at the patients that have true end-stage renal disease, are on dialysis, or were in a rhythm consistent with severe hyperkalemia prior to cardiac arrest. This aligns with the indications listed in the medical directive.
Education Links
LITFL for EKG changes expected with HyperK: https://litfl.com/hyperkalaemia-ecg-library/
If Wide QRS PEA is the initial rhythm, there may be an association with hyperK but this is not specific to asystole than becomes PEA: https://www.sciencedirect.com/science/article/abs/pii/S0735675721001327
COCA trial : https://www.sciencedirect.com/science/article/pii/S0300957222007122
Systematic Review from 2022 on Calcium use in cardiac arrest: https://pmc.ncbi.nlm.nih.gov/articles/PMC9550532/
Interesting NAESMP summary of calcium in OHCA: https://naemsp.org/2023-4-19-calcium-in-out-of-hospital-cardiac-arrest/
Interesting summary of recommended therapies for management if HyperK in cardiac arrests as well: https://emergencymedicinecases.com/emergency-management-hyperkalemia/
If Wide QRS PEA is the initial rhythm, there may be an association with hyperK but this is not specific to asystole than becomes PEA: https://www.sciencedirect.com/science/article/abs/pii/S0735675721001327
COCA trial : https://www.sciencedirect.com/science/article/pii/S0300957222007122
Systematic Review from 2022 on Calcium use in cardiac arrest: https://pmc.ncbi.nlm.nih.gov/articles/PMC9550532/
Interesting NAESMP summary of calcium in OHCA: https://naemsp.org/2023-4-19-calcium-in-out-of-hospital-cardiac-arrest/
Interesting summary of recommended therapies for management if HyperK in cardiac arrests as well: https://emergencymedicinecases.com/emergency-management-hyperkalemia/