<prompt> A 50 years old female patient who was on losartan and spironolactone therapy for her hypertension developed hypotension and bradycardia. The ECG taken is as below. Effective treatment for herTemporary facing by right femoral veinIntravenous nor adrenalinephenylephrineIV calcium gluconate followed by IV sodium bicarbonate300J DC shock  <response>: Answer: c IV calcium gluconate followed by IV sodium bicarbonateHYPERKALEMIAPlasma K concentration 5.5 mmolLPseudohyperkalemiaCellular efflux: thrombocytosis, erythrocytosis, leukocytosis, in vitro hemolysisHereditary defects in red cell membrane transport Renal failure distal flow effective circulating volume Tubular secretory failure K secretion Impaired Na reabsorption1deg,2degand pseudohypoaldosteronism chloride reabsorptionGordons yndrome, cyclosporineDrugs ACE inhibitors Amiloride Cytotoxic drugs Digitalis overdose Heparin Lithium NSAIDs Pentamidine Spironolactone Succinyl choline TriamtereneEarly ECG changes of hyperkalemia Serum potassium level 5.5-6.5 mEqLTall, peaked T waves with a narrow base, best seen in precordial leadsShortened QT intervalST-segment depressionSerum potassium level of 6.5-8.0 mEqLPeaked T wavesProlonged PR intervalDecreased or disappearing P waveWidening of the QRSAmplified R waveSerum potassium level higher than 8.0 mEqLAbsence of P waveProgressive QRS wideningIntraventricularfascicularbundle branch blocksThe progressively widened QRS eventually merges with the T wave, forming a sine wave pattern. Ventricular fibrillation or asystole follows.Treatment of Hyperkalemia: indicated if the plasma Kconcentration exceeds 6.5 mmoll.Immediate antagonism of the cardiac effects of hyperkalemia Stabilize cell membrane potentialI.V. calcium gluconateRapid reduction in plasma K concentration by redistribution into cells. Inhale b2 agonist salbutamol I.V. glucose 50ml of 50 solution and insulin 5U ActrapidShift K into cells but no role in acute hyperkalemiaI.V. sodium bicarbonateRemove K from body I.V. furosemide and NS Cation-exchange resins sodium polystyrene sulfonate-SPS orally or rectally Hemodialysis - most effective and reliable method 