Hypercalcemia: Difference between revisions

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==Background==
==Background==
High >10.5 meq/L (>2.7 ionized)
*High >10.5 meq/L (>2.7 ionized)
*High! >12.0 meq/L
*80% of cases associated with malignancy (most common among inpatients) or hyperparathyroidism (most common among outpatients)<ref>Pfennig CL, Slovis CM. Electrolyte disorders. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Saunders; 2018:(Ch) 117.</ref>
*Symptoms most correlated with rate of rise of Ca, not absolute level


High! >12.0 meq/L
==Clinical Features==
{{Hypercalcemia clinical features}}


==Diagnosis==
==Differential Diagnosis==
#stones (renal calculi)
{{Hypercalcemia DDX}}
#bones (bone destruction)
#psychic moanes (lethargy/confusion)
#abd groans (abd pain, constipation, polyuria, polydipsia)
#cardiac arrest (>20meq/L)
#ECG: shortened QT; heart block; depressed STs


==Work-Up==
==Evaluation==
#check phosphate, amylase, ua
===Work-Up===
#ekg for prolonged PR & QRS, decreased QT interval, heart block
*Calcium
*Phosphate, Magnesium
*PTH
*Lipase
*[[Urinalysis]]
*[[ECG]]
*Ionized Ca


==DDX==
===[[ECG]] Findings===
===Causes===
*Prolonged PR & QRS
#Hypothyroid
*Widened T waves
#Malignancy (mult myeloma, breast, lung, renal, leukemia, pancreatic)
*[[bradycardia|Bradyarrhythmia]]s / [[heart block]]
#Addison's
*[[Short QT]]
#Paget's
*STE/STD, can mimic [[Myocardial Infarction]]<ref>Littmann L, Taylor L 3rd, Brearley WD Jr. ST-segment elevation: a common finding in severe hypercalcemia. J Electrocardiol. 2007 Jan;40(1):60-2.</ref><ref>Donovan J, Jackson M. Hypercalcaemia Mimicking STEMI on Electrocardiography. Case Rep Med. 2010;2010:563572. doi:10.1155/2010/563572</ref>
#Sarcoid
#Hyperthyroid
#Milk-alkali synd
#Excess vit D
#Thiazides
#Inc parathyroid


==Treatment==
==Management==
===Indications===
{{Hypercalcemia treatment}}
#>12.0 meq/L
#symptomatic
#unalbe to tolerated POs
#abnl renal fx


===Treatment===
==Disposition==
#Correct dehydration (NS 5-10L)
{| {{table}}
##aim UOP = 500cc/hr
| align="center" style="background:#f0f0f0;"|'''Calcium'''
#Lasix (40-200mg IV Q1-2hr PRN dec UOP)
| align="center" style="background:#f0f0f0;"|'''Disposition'''
#Correct hypokalemia/hypomagnesemia
|-
#^Calcitonin 0.5-4 IU/kg IV over 24hrs
| <12||Home with follow up
#^Hydrocortisone 25-100mg IV Q6
|-
#^Dialysis if anuric, RF, or CHF
| 12-14||Depends
 
|-
^if Rxs 1-3 unsuccsessful
| >14||
*No [[ECG]] changes: Admit ward
*[[ECG]] changes: Admit telemetry
|}


==See Also==
==See Also==
Hem/Onc: Hypercalcemia of Malignancy
*[[Hypercalcemia of Malignancy]]


==Source ==
==References==
2/12/06 DONALDSON (adapted from Tintinalli, Mistry)
<references/>


[[Category:FEN]]
[[Category:FEN]]

Latest revision as of 21:07, 18 January 2021

Background

  • High >10.5 meq/L (>2.7 ionized)
  • High! >12.0 meq/L
  • 80% of cases associated with malignancy (most common among inpatients) or hyperparathyroidism (most common among outpatients)[1]
  • Symptoms most correlated with rate of rise of Ca, not absolute level

Clinical Features

Symptoms of hypercalcemia

Mnemonic: Stones, Bones, Groans, Moans, Thrones, Psychic Overtones

Differential Diagnosis

Causes of Hypercalcemia

Evaluation

Work-Up

  • Calcium
  • Phosphate, Magnesium
  • PTH
  • Lipase
  • Urinalysis
  • ECG
  • Ionized Ca

ECG Findings

Management

Asymptomatic or Ca <12 mg/dL

  • Does not require immediate treatment
  • Advise to avoid factors that can aggravate hypercalcemia (thiazide diuretics, Li, volume depletion, prolonged inactivity, high Ca diet)

Mildly symptomatic Ca 12-14 mg/dL

  • May not require immediate therapy; however, an acute rise may cause symptoms necessitating treatment as described for severe hypercalcemia (see below)

Symptomatic or Severe hypercalcemia (Ca >14 mg/dL)

  • Patients are likely dehydrated and require saline hydration as initial therapy

Hydration

  • Isotonic saline at 200-300 mL/hour; adjust to maintain urine output at 100-150 mL/hour

Calcitonin

  • Consider adding calcitonin 4 units/kg SC or IV q12hr in patients w/ Ca >14 mg/dL (3.5 mmol/L) who are also symptomatic (lowers Ca w/in 2-4hr)
  • Tachyphylaxis limits use long term, but is a great choice for emergent cases

Bisphosphonates

Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)[≥12 mg/dL][≥3 mmol/L][4]

  • Pamidronate 90mg IV over 24 hours OR
  • Zoledronate 4mg IV over 15 minutes
  • Caution in renal failure, though bisphosphonates have been safely used in pts with pre-existing renal failure[5]

Electrolyte Repletion

Diuresis

  • Furosemide is NOT routinely recommended
  • Only consider in patients with renal insufficiency or heart failure and volume overload

Dialysis

Consider if patient:

  • Anuric with renal failure
  • Failing all other therapy
  • Severe hypervolemia not amenable to diuresis
  • Serum Calcium level >18mg/dL
  • Neurologic symptoms
  • Heart failure with reduced ejection fraction (unable to provide fluids)

Corticosteroids

Decrease Ca mobilization from bone and are helpful with steroid-sensitive tumors (e.g. lymphoma, MM)

Disposition

Calcium Disposition
<12 Home with follow up
12-14 Depends
>14
  • No ECG changes: Admit ward
  • ECG changes: Admit telemetry

See Also

References

  1. ↑ Pfennig CL, Slovis CM. Electrolyte disorders. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Saunders; 2018:(Ch) 117.
  2. ↑ Littmann L, Taylor L 3rd, Brearley WD Jr. ST-segment elevation: a common finding in severe hypercalcemia. J Electrocardiol. 2007 Jan;40(1):60-2.
  3. ↑ Donovan J, Jackson M. Hypercalcaemia Mimicking STEMI on Electrocardiography. Case Rep Med. 2010;2010:563572. doi:10.1155/2010/563572
  4. ↑ Shane et al. Uptodate: Treatment of Hypercalcemia. https://www.uptodate.com/contents/treatment-of-hypercalcemia#disclaimerContent
  5. ↑ LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.
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