HYPERCALCEMIA

Question 1

MANAGEMENT

Answer 1

SEVERE (hypercalcemic crisis): 3.5-4 mol/L

1. IV FLUID:

NS IV bolus 30 ml / kg
Until BP and perfusion normalize
THEN
NS at 200-300 mL/h

Target U/O at 2 L / d

2. CALCITONIN: after adequate hydration

4 IU/kg intramuscular (IM) or subcutaneous (SC) q12h

MODERATE: 3-3.5 mmol/L:

IV FLUID:

NS IV bolus 30 ml / kg
Until BP and perfusion normalize
THEN
NS at 200-300 mL/h

Target U/O at 2 L / d

ASYMPTOMATIC / MILD: 2.63 mmol/L

Avoid potential causitive agents (eg, thiazides, vitamin D)

HYPERCALCEMIA OF MALIGNANCY:

1. BISPHOSPHONATES:

Zoledronic acid 4 mg IV over 15 min or
Pamidronate 60-90 mg IV over 2-24 h

2. PREDNISONE
   60 mg PO q24 hr
3. HEMODYALISIS
   Refractory to medical management
   OR
   cardiac dysfunction
   OR
   Severe neurological dysfunction

INVESTIGATIONS
Calcium
Pho
Mg
Albumin
Ionized Calcium
Creatinine
PTH
TSH
Lytes
ALP
Lipase (if abdominal pain)
CXR (consideration of malignancy)

CORRECTED CALCIUM
Measured total Ca (mmol/L) + 0.02(40- serum albumin [grams/L])

Question 2

DOCUMENTATION

Answer 2

CLINICAL FEATURES
ASYMPTOMATIC
STONES (renal calculi, renal failure)
BONES (bone pain, arthralgia, osteoporosis)
ABDOMINAL GROANS (N/V, anorexia, abdominal pain, constipation, peptic ulcer disease, pancreatitis)
THRONES (polyuria / polydipsia, dehydration, nephrogenic DI))
PSYCHIATRIC OVERTONES (Lethargy, AMS, Hallucinations)
COMA

HISTORY
Ask about:
Known hypercalcemia
Parathyroid hormone
Malignancy

PHYSICAL EXAM
Mental Status
Neurologic
Volume Status

ECG
Shortened PR
Shortening QTc
Depressed ST segment
Widened T waves

SEVERITY
Mild: 2.6-3 mmol/L
Moderate: 3-3.5 mmol/L
Severe (hypercalcemic crisis): 3.5-4 mmol/L

CORRECTED CALCIUM
Measured total Ca (mmol/L) + 0.02(40- serum albumin [grams/L])

Question 3

DDx

Answer 3

Primary Hyperparathyroidism
Hypercalcemia of Malignancy