EKG manifestations are not consistent or indicative of severity of hyperkalemia. The challenge in managing hyper-kalemia comes from the fact that it can be difficult, if not impossible, to identify the condition solely based on EKG information. Management of potassium should be guided by clinical scenario and serial potassium meas- urements. Because of such variability in the clinical pre- sentation of hyperkalemia and inconsistency and absence of changes in EKG, recognition of patients with severe hyperkalemia continues to be challenging to clinicians and initiation of appropriate therapy may be delayed.