Pifalls
You should keep the following points in mind when treating patients in the ED:
Diagnosis
- Remember to remove the tourniquet prior to venesection to avoid elevation of calcium
- Severe dehydration can elevate albumin and hence calcium levels
- Remember to correct for albumin elevation
- Consider hypercalcaemia in patients with multiple nonspecific complaints and an associated lung mass
Hypercalcaemia
- Urgent rehydration is required in acute hypercalcaemia which is an emergency
- Remember the diagnosis of hypercalcaemia is most often made on asymptomatic patients during routine analysis
- Hypercalcaemia in 90% of cases is due to hyperparathyroidism or malignancy, these must be ruled out early in a work up
- Hypercalcaemia of malignancy may lack many of the features commonly associated with hypercalcaemia caused by hyperparathyroidism. In addition, the symptoms of elevated calcium level may overlap with the symptoms of the patient’s malignancy
- Hypercalcaemia associated with renal calculi, joint complaints, and ulcer disease is more likely to be caused by hyperparathyroidism
Hypocalcaemia
- Symptomatic hypocalcaemia requires immediate treatment. Established tetany and seizures will require intravenous replacement
Management/Treatment
- Remember IV calcium chloride causes problems when extravasation occurs. Slow infusion is necessary, owing to the small serum pool of calcium, and hypercalcaemia is easily caused
- Parenteral calcium therapy is contraindicated in patients receiving cardiac glycosides. Give cautiously to patients with impaired renal function, cardiac disease, or sarcoidosis
- Severe elevations in calcium levels may cause coma
- Elderly patients are more likely to be symptomatic from moderate elevations of calcium levels
- Never prescribe furosemide without ensuring adequate hydration
- Never prescribe corticosteroids prior to proper evaluation of hypercalcaemia