Hypercalcemia
(Redirected from Hypercalcemic Crisis)
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
- "Stones"
- "Bones"
- Bone pain/destruction
- "Groans"
- "Thrones"
- Polyuria/polydipsia (Renal insufficiency)
- Constipation
- "Psychic Overtones"
Differential Diagnosis
Causes of Hypercalcemia
- Addison's disease
- Calciphylaxis
- Excess vitamin D
- Hypercalcemia of malignancy
- Hyperparathyroidism
- Hyperthyroidism
- Hypothyroidism
- Lithium
- Milk-alkali syndrome
- Paget disease
- Sarcoidosis
- Thiazide diuretics
Evaluation
Work-Up
- Calcium
- Phosphate, Magnesium
- PTH
- Lipase
- Urinalysis
- ECG
- Ionized Ca
ECG Findings
- Prolonged PR & QRS
- Widened T waves
- Bradyarrhythmias / heart block
- Short QT
- STE/STD, can mimic Myocardial Infarction[2][3]
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
- Correct hypokalemia
- Correct hypomagnesemia
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)
- Prednisone 60mg PO daily
Disposition
| Calcium | Disposition |
| <12 | Home with follow up |
| 12-14 | Depends |
| >14 |
See Also
References
- ↑ 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.
- ↑ 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.
- ↑ Donovan J, Jackson M. Hypercalcaemia Mimicking STEMI on Electrocardiography. Case Rep Med. 2010;2010:563572. doi:10.1155/2010/563572
- ↑ Shane et al. Uptodate: Treatment of Hypercalcemia. https://www.uptodate.com/contents/treatment-of-hypercalcemia#disclaimerContent
- ↑ LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.