eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic
Hypocalcemia: Treatment & Medication
Updated: Mar 9, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Standard advanced cardiac life support (ACLS) procedures should be initiated in the patient whose condition is unstable. No specific therapy, other than supportive care, is recommended.
Emergency Department Care
Most hypocalcemic emergencies are mild and require only supportive treatment and further laboratory evaluation. On occasion, severe hypocalcemia may result in seizures, tetany, refractory hypotension, or arrhythmias that require a more aggressive approach.
- Mild hypocalcemia (when symptoms are not life threatening)
- Confirm ionized hypocalcemia and check other pertinent laboratory tests.
- If the cause is not obvious, send for a PTH level.
- Depending on the PTH level, the endocrinologist may do further laboratory workup, particularly an evaluation of vitamin D levels.
- Oral repletion may be indicated for outpatient treatment; patients requiring intravenous (IV) repletion should be admitted. (Recommended dose of elemental calcium in healthy adults is 1-3 g/d.)
- Severe hypocalcemia (life-threatening symptoms)
- Supportive treatment often is required prior to directed treatment of hypocalcemia (ie, IV replacement, oxygen, monitoring). Be aware that severe hypocalcemia often is associated with other life-threatening conditions.
- Check ionized calcium and other pertinent screening laboratory tests.
- IV replacement is recommended in severe cases. Doses of 100-300 mg of elemental calcium (calcium gluconate – 10 mL contains 90 mg elemental calcium; calcium chloride – 10 mL contains 272 mg elemental calcium) should be given over 5-10 minutes. This dosage raises the ionized level to 0.5-1.5 mmol and should last 1-2 hours. Caution should be used when giving CaCl intravenously (see Medication).
- Calcium infusion drips should be started at 0.5 mg/kg/h and increased to 2 mg/kg/h as needed, with an arterial line placed for frequent measurement of ionized calcium.
Consultations
Depending on the clinical situation, multiple consultations may be necessary, including internist, endocrinologist, intensivist, surgeon, oncologist, nephrologist, dietitian, and/or toxicologist.
Medication
In the ED, magnesium and calcium (in their many different forms) are the only medications necessary to treat hypocalcemic emergencies. The consulting endocrinologist may choose to prescribe any of the various vitamin D supplements depending on laboratory workup findings and oral calcium supplementation for outpatient therapy.
Electrolyte supplements
These agents are used to increase blood calcium levels.
Calcium citrate (Citracal)
Oral formulation usually used as supplementation to IV calcium therapy. Moderates nerve and muscle performance by regulating action potential excitation threshold and facilitating normal cardiac function. Give amount needed to supplement diet to reach recommended daily amounts. Amount of elemental calcium in calcium citrate is 200 mg.
Adult
1-2 g PO divided bid/qid
Pediatric
45-65 mg/kg/d PO divided qid
May increase effect of quinidine; may decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; large intakes of dietary fiber may decrease absorption and levels
Documented hypersensitivity; hypercalcemia; hypophosphatemia; renal calculi; renal or cardiac disease; digitalis toxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypercalcemia or hypercalcuria may occur when therapeutic amounts are given; caution in digitalized patients and respiratory failure or acidosis
Calcium chloride
Moderates nerve and muscle performance by regulating action potential excitation threshold. Used when ventricular fibrillation is not associated with hyperkalemia, digitalis toxicity, hypercalcemia, renal insufficiency, or cardiac disease. Preferred when patient is in cardiac arrest and in other serious cases. The 10% IV solution provides 100 mg/mL of calcium chloride that equals 27.2 mg/mL (1.4 mEq/mL) of elemental calcium (10 mL of calcium chloride 10% contain 272 mg of elemental calcium).
DOC for patients in cardiac arrest.
Adult
100-300 mg elemental calcium IV diluted in 150 mL D5W over 5-10 min; initial rate of infusion is 0.3-2 mg of elemental calcium/kg/h
Pediatric
0.2 mL/kg/dose IV for patients in cardiac arrest
Coadministration with digoxin may cause arrhythmias; with thiazides, may induce hypercalcemia; may antagonize effects of calcium channel blockers, atenolol, and sodium polystyrene sulfonate
Documented hypersensitivity; ventricular fibrillation not associated with hyperkalemia; digitalis toxicity; hypercalcemia; renal insufficiency; cardiac disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Administer slowly (not to exceed 0.5-1 mL/min) to avoid extravasation; hypercalcemia may occur in renal failure
Calcium carbonate (Oystercal)
Used orally as supplementation to IV calcium therapy. Moderates nerve and muscle performance by regulating action potential excitation threshold.
Amounts of elemental calcium in calcium carbonate are as follows: Tums - 200 mg; Rolaids - 220 mg; Os-Cal - 500 mg.
Adult
1-2 g PO divided bid/qid
Pediatric
45-65 mg/kg/d PO divided qid
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; large intakes of dietary fiber may decrease absorption and levels
Documented hypersensitivity; renal calculi; hypercalcemia; hypophosphatemia; renal or cardiac disease; digitalis toxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in digitalized patients and respiratory failure or acidosis
Calcium gluconate (Kalcinate)
Useful in treating hypocalcemia. Moderate nerve and muscle performance by regulating action potential excitation threshold.
DOC for patients not in cardiac arrest (90 mg of elemental calcium in 10 mL of 10% solution). Oral formulation usually used as supplementation to IV calcium therapy. Amounts of elemental calcium in calcium gluconate are as follows: 500-mg tablet - 45 mg; 650-mg tablet - 58.5 mg; 975-mg tablet - 87.75 mg; 1-g tablet - 90 mg.
Adult
Parenteral: 100-300 mg elemental calcium IV diluted in 150 mL D5W over 5-10 min; initial rate of infusion is 0.3-2 mg of elemental calcium/kg/h
Oral: 1-2 g PO divided bid/qid
Pediatric
Parenteral: 1 mL (100 mg)/kg/dose IV continuous infusion over 24 h for patients not in cardiac arrest
10-20 mg/kg of elemental calcium IV over 5-10 min
Oral: 45-65 mg/kg/d PO divided qid
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; IV administration antagonizes effects of verapamil; large intakes of dietary fiber may decrease absorption and levels
Documented hypersensitivity; renal calculi; hypercalcemia; hypophosphatemia; renal or cardiac disease; digitalis toxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adverse effects include hypertension, nausea, vomiting, flushing, and bradycardia; caution when administering to digitalized patients and to patients with respiratory failure, acidosis, or severe hyperphosphatemia
More on Hypocalcemia |
| Overview: Hypocalcemia |
| Differential Diagnoses & Workup: Hypocalcemia |
 Treatment & Medication: Hypocalcemia |
| Follow-up: Hypocalcemia |
| References |
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Further Reading
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
