Acute oral potassium overdose: the role of hemodialysis. J Med Toxicol. 2011;7:52-56. [PMID: 20721655 DOI: 10.1007/s13181-010-0106-6]

Detection of Fatal Potassium Overdose: A Case Report and Review of the Literature

Potassium overdose usually occurs accidentally, but potassium is also used for judicial executions, assisted death, and, rarely, suicides. In addition to exogenous overdose, various drugs, and renal failure, diabetic ketoacidosis can cause hyperkalemia. Potassium tablets are used in most cases of suicidal potassium overdose. Suicide by intravenous administration of potassium is rare but usually fatal. The author reports a rare case of suicide with potassium infusion. Autopsy and histology findings, along with post-mortem biochemical analysis of different body fluids and fluid from the infusion set, are reported. Previously published reports of potassium overdose were reviewed, and the detection possibilities of potassium overdose are discussed. The detection possibilities of lethal hyperkalemia are very limited since hyperkalemia produces only nonspecific autopsy and histology findings. Post-mortem potassium concentrations are not indicative of ante-mortem potassium concentrations; therefore, post-mortem biochemical analysis has limited value in determining potassium overdose. The best way to prove potassium overdose is via the collection and analysis of circumstantial evidence.

Vitamin and mineral supplement exposures: cases reported to Australia's largest Poisons Information Centre, 2014-2015 to 2018-2019

Vitamin and mineral supplements (VMS) are widely available and commonly used. Little is known about patterns of poisoning exposures to VMS in the Australian population. We performed a retrospective study of calls to the New South Wales Poisons Information Centre (NSWPIC), July 2014-June 2019. NSWPIC is Australia's largest PIC, taking approximately 100 000 calls/year (50 % of Australian poisoning calls) from healthcare professionals and members of the public. We conducted additional analyses on Fe exposures due to their high risk of acute toxicity. There were 10 944 VMS exposures reported to NSWPIC during the study period, increasing 9·6 % per annum over a 5-year period (95 % CI, 7·2, 12·1 %). Toddlers (1-4 years) accounted for 41·5 % (4546) of cases. Agents most commonly involved were multivitamins (n 3610), vitamin D (n 2080), Fe (n 1533) and Mg (n 804). In 17·7 % (1934) of cases, the call originated from hospital or the patient was referred to hospital by NSWPIC. Fe exposures increased by 14·0 % per year (95 % CI, 9·5, 18·5 %), and most were associated with high-strength products (> 45 mg elemental Fe per unit dose, n 1036). Fe exposures were hospitalised in 38 % of cases (n 583). We conclude that VMS exposures are increasing in Australia. Although most exposures can be managed at home, many required hospitalisation. Fe exposures are increasing and had higher rates of hospitalisation than other agents. VMS are often considered safe and without the potential for adverse effects, highlighting the importance of public education into the potential risks of misuse of these products.

Oral potassium overdose: a case series

OBJECTIVE

Severe toxicity from ingestions of oral sustained-release potassium is rare. While acute hyperkalaemia requires urgent intervention given the risk of cardiac toxicity, there is a lack of clinical consensus on optimal management. The aim of this study was to characterise the clinical manifestations of acute potassium overdose and its management approach.

METHODS

This is a retrospective case series of patients presenting following oral potassium overdose of ≥6000mg between January 2009 and December 2020 in Queensland, Australia as recorded in the state's Poisons Information Centre database and a tertiary Clinical Toxicology Unit database. Patients were identified from prospective databases maintained by both units and data were extracted from these in addition to medical records.

RESULTS

Thirteen presentations in eleven patients occurred in the twelve-year period. The median age was 35 years (range 14-55 years). The median dose ingested was 6.4 mmol/kg (range 0.9-30.8 mmol/kg). Severe hyperkalaemia >7mmol/L occurred in five patients, four with ingestions ≥60,000mg. All patients with hyperkalaemia received multiple modes of intracellular potassium shifting therapy. Four patients had endoscopic removal of pharmacobezoars. One also underwent whole bowel irrigation. Three presentations were managed with haemodialysis. All patients were discharged home with a median length of stay of 20 h.

CONCLUSION

Aggressive medical therapy to shift potassium into cells appears to be the mainstay of treatment in patients with normal renal function. Early decontamination may limit peak potassium concentrations. It is unclear if haemodialysis provides significant additional benefit in patients with normal renal function.

Hyperkalemic Emergency: When You Have Taken a Few Too Many KCl Tablets

Hyperkalemia is a common clinical problem that varies significantly in severity and indications for treatment. Hyperkalemic emergency exists when there are clinical signs or symptoms, including cardiac conduction abnormalities. The combination of nebulized albuterol and insulin with glucose is most effective for managing clinically significant hyperkalemia. Prompt recognition of hyperkalemic emergency, immediate interventions to lower extracellular potassium, and involvement of multiple disciplines (including critical care and nephrology) are essential to addressing this life-threatening presentation.

Suicide attempt using potassium tablets for congenital chloride diarrhea: A case report

BACKGROUND

Congenital chloride diarrhea (CCD) is a rare inherited disorder of intestinal electrolyte transport that results in a large wastage of electrolytes and water. Advances in substitution therapy using sodium chloride (NaCl) and potassium chloride (KCl) have dramatically improved survival for patients with CCD. Slow-release KCl is widely prescribed as a potassium supplement; however, it has also occasionally been used in suicide attempts, as potassium poisoning can generate life-threatening hyperkalemia.

CASE SUMMARY

A 26-year-old female presented to the emergency department (ED) with self-poisoning, having taken 30 tablets of slow-release KCl (total: 240 mmol potassium) following an auditory hallucination. The patient had been undergoing substitution therapy with NaCl and KCl for CCD and been followed up in the pediatric department. One month prior, she developed insomnia and anxiety and had consulted a psychiatrist. At the ED, although her general condition was good, she appeared agitated. Her serum potassium level was 7.0 mmol/L, indicating hyperkalemia, and electrocardiographic changes showed tenting of the T-waves. She responded to the administration of calcium gluconate, sodium bicarbonate, and insulin with glucose, and the serum potassium level improved. Finally, she was diagnosed with schizophrenia.

CONCLUSION

In CCD management, physicians should pay careful attention to patients’ extraintestinal issues, including psychological disorders that may emerge in adulthood.

Review of case reports on hyperkalemia induced by dietary intake: not restricted to chronic kidney disease patients

Hyperkalemia is a metabolic disturbance of the potassium balance that can cause potentially fatal cardiac arrhythmias. Kidney dysfunction and renin-angiotensin-aldosterone system inhibiting drugs are notorious for their tendency to induce hyperkalemia by decreasing the excretion of potassium. The role of dietary potassium intake in inducing hyperkalemia is less clear. We review and analyze the common presentation, laboratory, and electrocardiogram (ECG) findings and therapeutic options associated with dietary-induced hyperkalemia, and find evidence for hyperkalemia development in non-renal impaired patients. Thirty-five case reports including 44 incidences of oral intake-induced hyperkalemia were assessed, 17 patients did not suffer from kidney dysfunction. Mean age was 49 ± 20 years. Mean potassium concentration was 8.2 ± 1.4 mEq/l, most frequently caused by abundant intake of fruit and vegetables (n = 17) or salt substitutes (n = 12). In patients with normal kidney function, intake of salt substitutes or supplements was the main cause of hyperkalemia. Main symptoms encompassed muscle weakness (29.5%), vomiting (20.4%), and dyspnea (15.9%). When ECGs were performed (n = 30), abnormalities were present in 86.7% of cases. Treatment involved administration of insulin (n = 22), sodium/calcium polystyrene sulfonate (n = 14), and/or calcium gluconate (n = 14). Forty patients fully recovered. Three, non-renal impaired, patients passed away. These results offer insight into the clinical aspects of dietary-induced hyperkalemia and suggest that the common assumption that dietary-induced hyperkalemia is a condition of renal impaired patients might be incorrect.

Fatal intravenous injection of potassium: Is postmortem biochemistry useful for the diagnosis?

Fatal cases of potassium overdoses have traditionally been considered indemonstrable due postmortem biochemical investigation limits (mainly potassium determination in postmortem serum and vitreous humor). Nevertheless, some authors have expressed a divergent opinion over the years based on the results of their own investigations. In this study, we investigated left vitreous, right vitreous, postmortem serum from peripheral blood, postmortem serum from cardiac blood, urine, pericardial and cerebrospinal fluid potassium concentrations in 21 forensic autopsy cases. One of these was a case of accidental, fatal intravenous potassium injection in a hospitalized patient. The other twenty cases were subjects with various causes of death unrelated to potassium administration and comparable postmortem intervals. Our aim was to assess whether postmortem biochemical investigations performed in several biological samples may be useful in diagnosing exogenous potassium administration. No statistically significant differences were observed between the measured concentrations in the fatal case of potassium intravenous administration and the control cases in any of the tested samples. Potassium concentrations in the investigated case of exogenous potassium injection were within the range of those measured in the control cases, irrespective of the tested biological sample. Our findings corroborate the conclusions of former authors who highlighted that circumstantial evidence provides the greatest diagnostic contribution in situations of suspected potassium poisoning. This is due to the objective limitations demonstrated by postmortem biochemical investigations in such cases, even when potassium measurements are carried out in several biological samples of satisfying quality and within a relatively short postmortem interval.

Self-inflicted hyperkalemia: a case report

We present a case of a potentially lethal ingestion of potassium pills. After presentation, we briefly review the epidemiology and pathology of hyperkalemia.

Life-threatening hyperkalemia from cream of tartar ingestion

INTRODUCTION

Cream of tartar (potassium bitartrate) has a long history as a cooking aid and medicinal purgative. Despite containing large amounts of potassium, there are no well-documented cases of it causing toxicity. We report two cases in which intentional ingestions of cream of tartar resulted in life-threatening hyperkalemia. In addition, we briefly review the use of cream of tartar as a historical purgative.

CASE REPORTS

In both cases, individuals ingested a large quantity of cream of tartar in an effort to "clean themselves out". They manifested similar initial symptoms (vomiting), abnormal serum potassium (>8.0 mmol/L), and EKG's with peaked T waves. Both patients were treated for hyperkalemia and recovered without complication. A search for articles on an academic internet database failed to identify any cases specifically dealing with ill effects of potassium bitartrate and numerous websites continue to purport its beneficial health effects.

CONCLUSION

Ingestion of cream of tartar can potentially result in life-threatening hyperkalemia.

Decontamination and enhanced elimination in sustained-release potassium chloride poisoning

Potassium chloride poisoning can be potentially life-threatening, particularly in massive ingestions of sustained-release preparations. Profound hyperkalaemia, developing over several hours, can lead to cardiac arrhythmias and death. This case series reports three episodes of sustained-release potassium chloride poisoning in two individuals requiring whole bowel irrigation or haemodialysis. The first two episodes, in the same patient, illustrate the contrast between the successful use of decontamination versus the need for haemodialysis. The second case, in a child, illustrates the need for tertiary level paediatric expertise in managing this type of poisoning. Whole bowel irrigation with polyethylene glycol is a resource-intensive procedure most beneficial when large numbers of radio-opaque tablets are seen in the stomach. In cases where most of the tablet matter has already been absorbed, extracorporeal methods of rapidly reducing the total body burden of potassium, such as haemodialysis, might be life-saving.