• 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



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

ECG Findings


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


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


  • 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


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


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


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)


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


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

See Also


  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.