Dangerously elevated blood potassium is one of the few electrolyte emergencies that can kill within minutes, yet the drugs used to treat it carry their own serious risks. A narrative review synthesizing current emergency-department evidence clarifies which interventions genuinely save lives, which carry underappreciated hazards, and where clinical uncertainty persists — findings that matter to anyone living with chronic kidney disease, heart failure, or diabetes, conditions that collectively raise lifetime hyperkalaemia risk substantially.
The review, drawing on PubMed and EMBASE literature alongside major international guidelines, confirms intravenous calcium salts as the immediate priority when ECG changes are present or serum potassium reaches 6.5 mmol/L or higher — calcium stabilizes cardiac membranes within minutes but does not lower potassium itself. Insulin-glucose infusion remains the primary transcellular-shifting strategy, yet the review emphasizes that hypoglycaemia is a frequent and serious downstream consequence, particularly in non-diabetic patients with lower baseline glucose levels. Inhaled salbutamol (a beta-2 agonist) demonstrates a meaningful, synergistic potassium-lowering effect when paired with insulin, supporting its routine inclusion in combination protocols. The evidence base for sodium bicarbonate is judged limited, applicable mainly to patients with concurrent severe metabolic acidosis.
Several clinical tensions deserve attention beyond what the source highlights. Potassium-binding resins such as sodium polystyrene sulfonate have been used for decades, yet rigorous prospective trial data in acute emergency populations remain sparse — a striking gap given their widespread use. The hypoglycaemia risk associated with insulin-glucose protocols is often underweighted in busy emergency settings; this review's emphasis should prompt departments to standardize glucose-monitoring protocols post-treatment. From a longevity perspective, recurrent hyperkalaemia episodes are strongly associated with accelerated cardiovascular and renal decline, making emergency management the acute face of a chronic disease-management problem. This review is broadly confirmatory rather than paradigm-shifting, but its synthesis of practical clinical uncertainties — where guidelines are silent or conflicting — adds meaningful operational value for emergency clinicians. Single-study gaps, especially the lack of prospective ED-specific data on elimination agents, remain a genuine limitation.