Hypercalcemia in Emergency Medicine Treatment & Management

  • Author: Robin R Hemphill, MD, MPH; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Sep 1, 2010
 

Prehospital Care

Prehospital care is primarily supportive with management of the ABCs. If a patient has a history of hypercalcemia and displays evidence of acute hypercalcemia, immediately begin IV hydration.

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Emergency Department Care

The treatment of hypercalcemia depends on the level, the chronicity, and the underlying cause of the problem. In mild-to-moderate elevations of calcium, few treatment options may be available in the ED. A physical evaluation to help delineate the source of the elevation is always appropriate, as is a subsequent timely follow-up visit.

  • Initial goals of treatment
    • Stabilization and reduction of the calcium level
    • Adequate hydration
    • Increased urinary calcium excretion
    • Inhibition of osteoclast activity in the bone
    • Discontinuation of pharmacologic agents associated with hypercalcemia
    • Treatment of the underlying cause (when possible)
  • The initial step in the care of severely hypercalcemic patients is hydration with saline. Most of these patients are profoundly dehydrated. Hydration helps decrease the calcium level through dilution. The expansion of extracellular volume also increases the renal calcium clearance. The rate of fluid therapy is based upon the following:
    • Degree of hypercalcemia
    • Severity of dehydration
    • Ability of the patient to tolerate rehydration - Vigilance to prevent volume overload is critical.
    • Hydration is ineffective in patients with kidney failure because diuresis is impossible. Dialysis is necessary to correct hypercalcemia in patients with renal failure.
  • Loop diuretics
    • A loop diuretic (eg, furosemide) may be used with hydration to increase calcium excretion. This may also prevent volume overload during therapy.
    • In contrast to loop diuretics, avoid thiazide diuretics because they increase the reabsorption of calcium.
  • Bisphosphates - These agents will inhibit osteoclast activity for up to a month.
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Consultations

  • Patients with renal failure or heart failure may not be able to tolerate fluid hydration or some of the other medications. Patients in this group who present with severe elevations of calcium may require urgent dialysis. Consult a nephrologist immediately in such cases.
  • Patients with primary hyperparathyroidism may require surgery to eliminate the condition,[7] but surgery usually does not need to be performed on an urgent basis.
  • Patients with malignancy may require surgery, chemotherapy, or radiation treatment. Appropriate consultation should be undertaken.
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Contributor Information and Disclosures
Author

Robin R Hemphill, MD, MPH  Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Jeffrey L Arnold, MD, FACEP  Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References

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  6. Grill V, Ho P, Body JJ, et al. Parathyroid hormone-related protein: elevated levels in both humoral hypercalcemia of malignancy and hypercalcemia complicating metastatic breast cancer. J Clin Endocrinol Metab. Dec 1991;73(6):1309-15. [Medline].

  7. Diaz Guardiola P, Vega Pinero B, Alameda Hernando C, Pavon de Paz I, Iglesias Bolanos P, Guijarro de Armas G. [Primary hyperparathyroidism. An alternative to the surgery.]. Endocrinol Nutr. Mar 2009;56(3):132-5. [Medline].

  8. Bilezikian JP. Clinical review 51: Management of hypercalcemia. J Clin Endocrinol Metab. Dec 1993;77(6):1445-9. [Medline].

  9. Bilezikian JP. Management of acute hypercalcemia. N Engl J Med. Apr 30 1992;326(18):1196-203. [Medline].

  10. Kiang DT, Loken MK, Kennedy BJ. Mechanism of the hypocalcemic effect of mithramycin. J Clin Endocrinol Metab. Feb 1979;48(2):341-4. [Medline].

  11. Kinirons MT. Newer agents for the treatment of malignant hypercalcemia. Am J Med Sci. Jun 1993;305(6):403-6. [Medline].

  12. Stewart AF. Clinical practice. Hypercalcemia associated with cancer. N Engl J Med. Jan 27 2005;352(4):373-9. [Medline].

  13. Thirlwell C, Brock CS. Emergencies in oncology. Clin Med. Jul-Aug 2003;3(4):306-10. [Medline].

 
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