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Hyperkalemia is one of the few potentially lethal electrolyte disturbances. Prompt recognition and expeditious treatment of severe hyperkalemia are expected to save lives. This review is intended to provide intensivists and other interested clinicians with an understanding of the pathophysiology that underlies hyperkalemia, and a rational approach to its management.This article reviews and analyzes literature relevant to the pathophysiology and management of severe hyperkalemia. Methods include search of MEDLINE, and bibliographic search of current textbooks and journal articles.A more complete understanding of potassium homeostasis in recent years has led to new approaches to the management of severe hyperkalemia. The physiologically based sequential approach still applies. The efficacy, pitfalls, and risks of the agents available for use at each step in the sequence are critically reviewed. Rational use of the available tools will allow clinicians to successfully treat severe hyperkalemia.