In pediatric hyperkalemia, which treatment is given first?

• A. Albuterol: 10 mg Nebulized
• B. Sodium Bicarbonate: 1 mEq/kg IV/IO over 2 min
• C. Calcium Chloride: 20 mg/kg IV/IO over 2 min (FIRST)
• D. Normal Saline: 20 ml/kg (if hypotensive)

Answer: (C)

In pediatric hyperkalemia, the immediate priority is protecting the heart from the effects of high potassium. Calcium stabilizes the cardiac cell membranes, increasing the threshold for depolarization and reducing excitability. This “membrane stabilizer” effect helps prevent life-threatening arrhythmias while other measures are taken to lower or redistribute potassium. Because of this rapid protective action, calcium is given first.

The specific plan uses IV/IO calcium chloride to quickly stabilize the myocardium. After this stabilization, treatments that actually move potassium into cells (like insulin with glucose, beta-agonists such as albuterol, and bicarbonate if needed) or remove potassium (fluids if hypotensive, diuretics, or dialysis) can be pursued. Calcium does not lower the potassium level itself; it buys time to safely address the elevated potassium.