Hypercalcemia in Emergency Medicine Workup

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

Laboratory Studies

  • Confirmatory tests: Changes in serum protein concentrations alter the total serum calcium level but do not affect the unbound fraction. Calcium level reported by the laboratory usually represents the bound and unbound calcium. When calcium levels are reported as high or low, the physician must be able to calculate the actual level of calcium. A common formula is as follows: Corrected total calcium (mg/dL) = (measured total calcium mg/dL) + 0.8 (4.4 - measured albumin g/dL)The average normal albumin level is 4.4. The reference range for corrected value of calcium is approximately 9-10.6 mg/dL.
    • The corrected calcium value is useful in most situations, but individual variation can occur.
    • If the corrected serum calcium level still is not accurate, it is possible to measure the free calcium ion activity (ie, ionized calcium level).
  • Other nonspecific laboratory abnormalities commonly found in patients with hypercalcemia result from disordered renal function. Patients commonly have significant azotemia at presentation.
  • Hypercalcemia may produce ECG abnormalities related to altered trans-membrane potentials that affect conduction time. QT interval shortening is common, and, in some cases, the PR interval is prolonged. At very high levels, the QRS interval may lengthen, T waves may flatten or invert, and a variable degree of heart block may develop. Digoxin effects are amplified.
  • After a diagnosis of hypercalcemia is established, the next step is to determine the cause. Initial testing is directed at malignancy, hyperparathyroidism, and hyperthyroidism, the most common causes of hypercalcemia.
    • The measurement of circulating PTH in the serum is the most direct and sensitive measure of parathyroid function. A reference range is 2-6 mol/L. A nonsuppressed PTH level in the presence of hypercalcemia suggests a diagnosis of primary hyperparathyroidism. If the PTH level is suppressed in the face of an elevated calcium level, hyperparathyroidism is unlikely.
    • Parathyroid hormone-related peptide (PTHrP) is thought to mediate the hypercalcemia that develops with many malignancies. Assays to measure this peptide are available.[6]
    • Measurement of calcitriol is difficult but can be accomplished. This laboratory value is useful in diagnosing hypercalcemia secondary to a granulomatous disease such as sarcoidosis.
    • Other electrolytes also may be disturbed in hypercalcemia. Serum phosphate levels tend to be low or normal in primary hyperparathyroidism and hypercalcemia of malignancy. Phospate levels are elevated in hypercalcemia secondary to vitamin D–related disorders or thyrotoxicosis. Serum chloride levels usually are higher than 102 mEq/L in hyperparathyroidism and less than this value in other forms of hypercalcemia.
Next

Imaging Studies

  • No imaging studies definitively diagnose hypercalcemia.
  • Consider hypercalcemia in patients with multiple nonspecific complaints and an associated lung mass.
  • If laboratory evidence of primary hyperparathyroidism is present, CT scan of the head, MRI, ultrasound, or nuclear parathyroid scans may be helpful. Preoperative diagnostic imaging is essential in patients with previous neck surgery.
Previous
Proceed to Treatment & Management
 
 
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

  1. Ariyan CE, Sosa JA. Assessment and management of patients with abnormal calcium. Crit Care Med. Apr 2004;32(4 Suppl):S146-54. [Medline].

  2. Dent DM, Miller JL, Klaff L, Barron J. The incidence and causes of hypercalcaemia. Postgrad Med J. Sep 1987;63(743):745-50. [Medline].

  3. Edelson GW, Kleerekoper M. Hypercalcemic crisis. Med Clin North Am. Jan 1995;79(1):79-92. [Medline].

  4. Blomqvist CP. Malignant hypercalcemia--a hospital survey. Acta Med Scand. 1986;220(5):455-63. [Medline].

  5. Mundy GR, Guise TA. Hypercalcemia of malignancy. Am J Med. Aug 1997;103(2):134-45. [Medline].

  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].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.