How should hyperkalemia be managed acutely?

Severe hyperkalemia (>6.5 mEq/L or ECG changes) requires immediate intervention. Calcium gluconate stabilizes cardiac membranes (does not lower K+). Insulin with glucose drives potassium intracellularly. Beta-agonists provide additional shift. Elimination: loop diuretics if volume replete, sodium polystyrene sulfonate or patiromer for GI elimination, hemodialysis for severe/refractory cases. Address underlying cause and discontinue offending medications.