Urine Nephrology Now: A Primer for Students in Nephrology
Andrew Bland, MD
Chapter 26: Nephrology Emergencies
Severe Hyperkalemia (K+ >6.5 mEq/L or ECG changes)
Immediate Management Protocol
Stabilize the Cardiac Membrane: Calcium gluconate 1-2 amps IV. This is the first and most critical step to prevent fatal arrhythmias.
Shift Potassium Intracellularly: Regular insulin 10 units + D50W 25g IV, and/or high-dose nebulized albuterol (10-20 mg).
Enhance Elimination: Loop diuretics (if not anuric), potassium binders (e.g., SZC), and arrange for emergency dialysis if severe or refractory.
Severe Symptomatic Hyponatremia
Acute Management for Seizures or Coma
Administer a 100-150 mL bolus of 3% hypertonic saline over 10-20 minutes.
The goal is a rapid 4-6 mEq/L increase in serum sodium to alleviate acute cerebral edema.
May repeat bolus 1-2 times if symptoms persist.
Once symptoms improve, slow the correction rate to avoid exceeding 8-10 mEq/L in 24 hours to prevent osmotic demyelination syndrome.
Acute Pulmonary Edema
Emergency Protocol
Position: Sit the patient upright to reduce venous return.
Oxygen: High-flow oxygen or non-invasive ventilation (CPAP/BiPAP).
Diuretics: High-dose IV loop diuretics (e.g., Furosemide 80-160 mg). A common rule of thumb is to give double the patient's total daily oral dose as an IV bolus.
Vasodilators: Nitroglycerin (if hypertensive) to reduce preload and afterload.
Consider: Emergency dialysis if unresponsive to medical management or anuric.