Comprehensive Metabolic Panel (CMP)

Hyperkalemia with ECG changes or K⁺ 6.5 mEq/L or higher

Recognize: peaked T waves, PR prolongation, lost P waves, QRS widening, bradycardia or sine wave. When the ECG changes are present, treat now. Don't wait for a repeat level.

1. Protect the heart (Paramedic/RN/CCT): with a pulse and hyperkalemic ECG changes or arrhythmia, calcium gluconate 10%, 30 mL (3 g) IV over 10 min through a large vein (a peripheral vein will do). Use calcium chloride 10%, 10 mL (1 g) IV over 5 min for peri-arrest only, or through a central or large proximal vein, since a leak out of the vein does more harm than with gluconate. For cardiac arrest or peri-arrest, give calcium chloride 10%, 10 mL (1 g) IV/IO push (UKKA 2026 guideline). Look at the ECG again about 3 min after the dose. If the ECG changes persist, or K⁺ is still high after about 60 min, repeat the same dose. Keep calcium out of the same line as bicarbonate or phosphate. In suspected digoxin toxicity, IV calcium is for life-threatening hyperkalemia only, per medical direction. Differs from FDA label: US labels cover only hypocalcemia and cap the rate (calcium gluconate 200 mg/min for adults, so 3 g takes at least 15 min, and calcium chloride 1 mL/min through a central or deep vein with no bolus). The rate used on this page (gluconate 30 mL over 10 min, chloride 10 mL over 5 min) comes from UKKA 2026. It is off-label.
2. Shift K⁺ into cells: High-alert regular insulin 10 units IV, drawn up into the dextrose syringe along with dextrose 25 g (50 mL D50, or 125 mL D20, or 250 mL D10) and pushed over 5–15 min into a large vein. Recommended at K⁺ 6.5 or higher. Suggested at 6.0–6.4. Always give the dextrose. Do not swap in glucose alone. If K⁺ is still not below 6.0 at 2 hr, consider a second dose, and stretch out the glucose checks (UKKA 2026 guideline).
3. Prevent hypoglycemia: when pre-treatment glucose is under 126 mg/dL (7 mmol/L), run D10 50 mL/hr for 5 hr (UKKA 2026 guideline). Glucose gets checked before the dose and then at 30, 60, 90, 120, 180, 240, 300 and 360 min (at least 6 hr). Keep checking past 6 hr after repeat insulin doses, or in high-risk patients (low pre-dose glucose, kidney impairment, low body weight, older age). Glucose under 70 mg/dL gets the hypoglycemia steps below.
4. Adjunct: nebulized albuterol 10–20 mg (UKKA 2026: an adjunct only, not monotherapy for severe hyperkalemia). Stay at 10 mg in ischemic heart disease. Off-label dose (label nebulized dose is 2.5 mg for asthma). The 10–20 mg figure comes from UKKA 2026. High-dose albuterol drives the heart rate up and can provoke ischemia or arrhythmia. Go carefully in patients with ischemia or tachyarrhythmia. In cardiac arrest, the 2025 AHA Guidelines for CPR and ECC, Part 10 advise against inhaled beta-2 agonists (class 3: No Benefit, LOE C-EO).
5. Remove K⁺ and recheck: sodium zirconium cyclosilicate (Lokelma) 10 g PO three times daily for up to 48 hr, added on to calcium and insulin-glucose (US label; UKKA 2026 allows up to 72 hr). Differs from FDA label: the label warns against SZC as emergency treatment for life-threatening hyperkalemia, because it acts slowly. UKKA 2026 backs it as an add-on to calcium and insulin-glucose in severe hyperkalemia. A hemodialysis patient with K⁺ 6.5 or higher needs urgent dialysis (UKKA 2026 guideline). In any life-threatening or treatment-resistant case, ask for an urgent nephrology or critical-care decision on dialysis. Recheck K⁺ at 1, 2, 4, 6 and 24 hr. Rebound is common.

Note: Outside arrest, IV sodium bicarbonate is not routine for acute hyperkalemia (UKKA 2026 guideline). Calcium does not lower K⁺ at all. It protects the heart muscle while the K⁺ is being shifted. In cardiac arrest from suspected hyperkalemia (2025 AHA Guidelines for CPR and ECC, Part 10, Electrolyte Abnormalities: Hyperkalemia): For IV calcium (calcium chloride 10 mL, 1 g IV/IO push), the class is 2b (LOE C-LD), and IV sodium bicarbonate and IV insulin with glucose are also class 2b (LOE C-EO), since their effectiveness is still poorly established. In arrest without a suspected hyperkalemic cause, routine calcium is not recommended (2025 AHA Part 9, COR 3: No Benefit). Bicarbonate runs at 50 mEq IV/IO, repeated every 5–10 min guided by blood gas (US label; UKKA 2026 suggests, 2C). Inhaled beta-2 agonists sit at class 3: No Benefit. For adults in arrest, AHA Table 3 gives regular insulin 10 units IV over 15–30 min with D50 50 g. Differs from UKKA 2026 and ERC: They give 25 g, plus D10 50 mL/hr if glucose is under 126 mg/dL. AHA 2025 Table 3 gives 50 g. In hyperkalemic arrest, AHA rates insulin-glucose COR 2b, with effectiveness not well established. Some US protocols give 5 units or 0.1 units/kg instead. A pooled analysis of 10 retrospective studies found less hypoglycemia with lower doses, and the K⁺ fall did not differ (see References). A later study found that 10 units lowered K⁺ more (0.9 vs 0.63 mmol/L, see References). UKKA 2026 says more study is needed before 5 units can be recommended. The glucose rules above come with the 10 units this site uses.

Severe symptomatic hyponatremia (seizure, coma or respiratory distress)

Recognize: Think hypotonic hyponatremia with neurologic symptoms. Acute or chronic, treat now. If a sample is quick to draw, check the sodium and serum osmolality. Don't hold treatment for the result.

1. Airway and perfusion (Paramedic/RN/CCT): protect the airway, check the glucose, and give oxygen as needed.
2. High-alert 3% NaCl: 100–150 mL IV over 10–20 min. The US expert panel gives 100 mL over 10 min, repeated up to 3 times. The European guideline gives 150 mL over 20 min, repeated once or twice. Repeat as the protocol says.
3. Recheck sodium after each bolus. Aim for a 4–6 mEq/L rise to reverse the symptoms. In high-risk patients, cap the rise at 8 mEq/L per 24 hr (hypokalemia, alcohol use disorder, malnutrition, advanced liver disease). The US standard-risk limit is 10–12 mEq/L per 24 hr. The European limit is 10 mEq/L in the first 24 hr, then 8 mEq/L per later 24 hr. These limits are there to prevent osmotic demyelination.
4. Do not free-flow hypertonic saline: Run it as a timed bolus or per pump protocol.
5. If overcorrected or the limit is exceeded: shut off the hypertonic saline. Call for a consult on D5W and/or desmopressin to lower sodium again.

Hypoglycemia (glucose below 70 mg/dL with symptoms)

Recognize: Watch for sweating, confusion, seizure or unresponsiveness. Check glucose first in every altered patient, before you consider any other cause.

1. Alert and able to swallow: take 15–20 g of fast-acting carbohydrate by mouth (ADA Standards of Care, Section 6), then check glucose again per protocol.
2. Cannot swallow safely (Paramedic/RN/CCT): dextrose 10 g IV (100 mL of D10), given in 5 g steps, rechecking glucose after each step until alert. The field maximum is 25 g per dosing episode, then per medical direction (E3 dextrose page).
3. No IV or IO access: use glucagon 1 mg IM or subcutaneous (labeled routes), or intranasal or autoinjector glucagon where stocked, per protocol.
4. Sulfonylurea or long-acting insulin: expect it to come back, so keep watching for several hours after treatment.

Symptomatic hypocalcemia (tetany, seizure, QT prolongation or hypotension)

Recognize: carpopedal spasm, laryngospasm, seizure, QT prolongation. Check both ionized calcium and magnesium.

1. Calcium chloride 10%: 200–1,000 mg (2–10 mL) IV, go slowly, no faster than 1 mL/min. Maximum 1,000 mg per dose; repeat as the ionized calcium directs (labeled dose). A central or large vein is preferred.
2. Treat hypomagnesemia if it is present. Replace calcium without fixing magnesium and the hypocalcemia stays.
3. Massive transfusion: during massive transfusion, check ionized calcium with each blood gas and treat per the transfusion protocol.

Severe hypercalcemia or severe metabolic acidosis

Recognize: total Ca above 13 mg/dL (critical high) with confusion, vomiting or polyuria; or pH below 7.20 with low CO₂.

1. Hypercalcemia (RN/CCT): isotonic saline per protocol. Stop thiazides and other calcium-raising drugs. Transfer for definitive treatment.
2. Acidosis (ICU): start with the cause (insulin and fluids in DKA, perfusion in shock, toxic ingestion). Whether to give sodium bicarbonate depends on the protocol. It is not a routine step for hyperkalemia (UKKA 2026 guideline).

Severe hypokalemia (K⁺ below 2.5) or severe hypernatremia (Na⁺ above 160)

Recognize: hypokalemia with arrhythmia, weakness or paralysis; hypernatremia with confusion, seizure or altered consciousness. Treat per local protocol and medical direction.

1. Hypokalemia (ICU/CCT): Monitor the ECG continuously. Check and replace magnesium. IV potassium chloride through a pump at a controlled rate per protocol, never as a bolus, and repeat the level and ECG during replacement.
2. Hypernatremia (ICU): work out the free-water deficit and replace it by whatever route is open, correcting slowly (about 10–12 mEq/L per 24 hr, per protocol) so the brain does not swell. Recheck sodium at the protocol interval.