eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Hypocalcemia: Differential Diagnoses & Workup

Author: Christopher B Beach, MD, FACEP, FAAEM, Assistant Professor and Vice Chair, Department of Emergency Medicine, Assistant Professor of Institute for Healthcare Studies, Institute for Patient Safety, Feinberg School of Medicine, Northwestern University
Contributor Information and Disclosures

Updated: Mar 9, 2009

Differential Diagnoses

Hydrofluoric Acid Burns
Hypernatremia
Hypercalcemia
Hyperosmolar Hyperglycemic Nonketotic Coma
Hyperkalemia
Hyperparathyroidism
Hypermagnesemia
Hyperphosphatemia

Other Problems to Be Considered

Celiac sprue

Workup

Laboratory Studies

  • Symptomatic patients with classic clinical findings of acute hypocalcemia require immediate resuscitation and evaluation. However, most cases of hypocalcemia are discovered by clinical suspicion and appropriate laboratory testing.
  • Calcium levels
    • A serum calcium level less than 8.5 mg/dL or an ionized calcium level less than 1.0 mmol/L is considered hypocalcemia.
    • Analysis for ionized level must be performed rapidly with whole blood to avoid changes in pH and anion chelation. Blood should be drawn in an unheparinized syringe for best results.
    • Falsely elevated calcium levels may be seen with elevated acetaminophen levels, alcohol, hydralazine, and hemolysis.
    • Falsely depressed levels can be seen with heparin, oxalate, citrate, or hyperbilirubinemia.
  • Magnesium, phosphate, and other electrolyte levels should be obtained.
  • Elevated BUN and creatinine levels may indicate renal dysfunction.
  • Albumin, liver function studies, and coagulation parameters should be obtained to assess liver dysfunction and hypoalbuminemia.
  • The PTH level (an antibody-mediated radioimmunoassay) should be checked as early as possible.

Imaging Studies

  • Depending on the patient's clinical status and the suspected etiology of hypocalcemia, imaging studies may or may not be indicated in the ED.

Other Tests

  • ECG and electrocardiographic monitoring should be obtained to rule out dysrhythmias and a prolonged QT interval.

More on Hypocalcemia

Overview: Hypocalcemia
Differential Diagnoses & Workup: Hypocalcemia
Treatment & Medication: Hypocalcemia
Follow-up: Hypocalcemia
References
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References

  1. Russell CF, Edis AJ. Surgery for primary hyperparathyroidism: experience with 500 consecutive cases and evaluation of the role of surgery in the asymptomatic patient. Br J Surg. May 1982;69(5):244-7. [Medline].

  2. Abrunzo TJ. An infant fatality associated with inspiratory and expiratory wheezing: another wheeze that wasn't asthma. Pediatr Emerg Care. Feb 1995;11(1):48-51. [Medline].

  3. Bellazzini MA, Howes DS. Pediatric hypocalcemic seizures: A case of Rickets. J Emerg Med. Feb 2005;28(2):161-4. [Medline].

  4. Boden SD, Kaplan FS. Calcium homeostasis. Orthop Clin North Am. Jan 1990;21(1):31-42. [Medline].

  5. Bourke E, Delaney V. Assessment of hypocalcemia and hypercalcemia. Clin Lab Med. Mar 1993;13(1):157-81. [Medline].

  6. Chavan CB, Sharada K, Rao HB, Narsimhan C. Hypocalcemia as a cause of reversible cardiomyopathy with ventricular tachycardia. Ann Intern Med. Apr 3 2007;146(7):541-2. [Medline].

  7. Emerson J, Kost G. Spurious hypocalcemia after Omniscan- or OptiMARK-enhanced magnetic resonance imaging: an algorithm for minimizing a false-positive laboratory value. Arch Pathol Lab Med. Oct 2004;128(10):1151-6. [Medline].

  8. Guise TA, Mundy GR. Clinical review 69: Evaluation of hypocalcemia in children and adults. J Clin Endocrinol Metab. May 1995;80(5):1473-8. [Medline].

  9. Guyton AC. Parathyroid hormone, calcitonin, calcium and phosphate metabolism, vitamin D, bone and teeth. In: Medical Physiology. 8th ed. Philadelphia, PA: WB Saunders; 1991.

  10. Hurley K, Baggs D. Hypocalcemic cardiac failure in the Emergency Department. J Emerg Med. Feb 2005;28(2):155-9. [Medline].

  11. Kashket S, Zhang J, Van Houte J. Accumulation of fermentable sugars and metabolic acids in food particles that become entrapped on the dentition. J Dent Res. Nov 1996;75(11):1885-91. [Medline].

  12. Nguyen LT, Mohr WJ, Ahrenholz DH. Treatment of hydrofluoric acid burn to the face by carotid artery infusion of calcium gluconate. J Burn Care Rehabil. Sep-Oct 2004;25(5):421-4. [Medline].

  13. NIH Consensus Development Conference. Optimal calcium intake. NIH Consensus Development Program and Abstracts. 1994. [Medline].

  14. Reber PM, Heath H. Hypocalcemic emergencies. Med Clin North Am. Jan 1995;79(1):93-106. [Medline].

  15. Rickels MR, Mandel SJ. Celiac disease manifesting as isolated hypocalcemia. Endocr Pract. May-Jun 2004;10(3):203-7. [Medline].

  16. Sorva A. 'Correction' of serum calcium values for albumin biased in geriatric patients. Arch Gerontol Geriatr. Jul-Aug 1992;15(1):59-69. [Medline].

  17. Tohme JF, Bilezikian JP. Hypocalcemic emergencies. Endocrinol Metab Clin North Am. Jun 1993;22(2):363-75. [Medline].

  18. Ungvari Z, Pacher P, Koller A. Serotonin reuptake inhibitor fluoxetine decreases arteriolar myogenic tone by reducing smooth muscle [Ca2+]i. J Cardiovasc Pharmacol. Jun 2000;35(6):849-54. [Medline].

  19. Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. Dec 27 2006;296(24):2947-53. [Medline].

  20. Zaloga GP. Hypocalcemia in critically ill patients. Crit Care Med. Feb 1992;20(2):251-62. [Medline].

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Further Reading

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Keywords

hypocalcemia, calcium, calcium regulation, smooth muscle contraction, hypoalbuminemia, calcitonin, calcium homeostasis, spurious hypocalcemia, calcium gluconate, hyperparathyroidism, celiac sprue, low calcium, low blood calcium, calcium deficiency, ionized hypocalcemia, cardiovascular collapse, hypotension, dysrhythmias, tetany, seizures, muscle cramping, bronchospasm, tetanic contractions, distal extremity numbness, tingling sensations, cataracts, psoriasis, chronic pruritus, syncope, congestive heart failure, CHF, angina, laryngeal stridor, dysphagia, biliary colic, intestinal colic, gluten intolerance, preterm labor, detrusor dysfunction, focal numbness, muscle spasms, Chvostek sign, Trousseau sign, carpal spasm, irritability, confusion, hallucinations, dementia, extrapyramidal manifestations, hypomagnesemia, hyperphosphatemia, PTH deficiency, PTH resistance, vitamin D deficiency, vitamin D resistance, cirrhosis, nephrosis, malnutrition, burns, sepsis, acute pancreatitis, alcoholism, rhabdomyolysis, toxic shock syndrome, high calcitonin levels, osteoblastic metastases, breast cancer, prostate cancer, tumor lysis syndrome, hepatic insufficiency, renal insufficiency, sarcoidosis, tuberculosis, hemochromatosis, hydrofluoric acid burn, hydrofluoric acid ingestion, renal failure, mesenteric ischemia, massive blood transfusion, radiocontrast dyes, high bicarbonate levels, high lactate levels, parathyroid adenoma resection, parathyroid injury, pancreatectomy, small bowel syndrome, DiGeorge syndrome, idiopathic hypoparathyroidism, Wilson disease, metastatic cancer, pseudohypoparathyroidism, Albright disease, rickets, hepatorenal disease

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Contributor Information and Disclosures

Author

Christopher B Beach, MD, FACEP, FAAEM, Assistant Professor and Vice Chair, Department of Emergency Medicine, Assistant Professor of Institute for Healthcare Studies, Institute for Patient Safety, Feinberg School of Medicine, Northwestern University
Christopher B Beach, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robin R Hemphill, MD, MPH, Associate Professor, Director, Disaster Preparedness, Department of Emergency Medicine, Vanderbilt University Medical Center
Robin R Hemphill, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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