Hypercalcemia in Emergency Medicine Follow-up

Updated: Apr 11, 2018
  • Author: Thomas E Green, DO, MPH, MMM, CPE, FACEP, FACOEP; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Follow-up

Further Outpatient Care

Patients with primary hyperparathyroidism who present with symptoms of severe or moderate elevations of calcium levels should be referred for parathyroidectomy. This referral may be urgent, depending on the severity of the hypercalcemia.

Patients with mild-to-moderate elevations of calcium who have no symptoms may be evaluated on an outpatient basis and usually are treated medically. For those patients with malignancy as the cause of their hypercalcemia, a cure may not be possible. The ideal scenario finds a treatable underlying cause for hypercalcemia and allows the physician to attend to this primary process. If this is accomplished, the patient may not need therapy for the hypercalcemia itself.

The drug regimen most appropriate for each individual depends on the cause of the elevation and usually is not managed by the ED physician. Patients may require ongoing treatment for calcium elevation. This type of treatment can be frustrating and difficult, and it is not always successful.

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Further Inpatient Care

Serum calcium level generally responds to fluids and Lasix; however, this therapy has no effect on the principle pathologic process causing hypercalcemia. Additional therapy must be added to the temporizing treatment described above.

Treatment of the underlying disease must be addressed.

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Transfer

Transfer may be considered in a number of situations.

  • If a patient presents with severe hypercalcemia and renal failure, emergency dialysis is necessary. Consider transfer if this is unavailable at the initial treatment center.

  • If no intensivist or physician familiar with the inpatient treatment of hypercalcemia is available, consider transferring patients with normal kidney function who are being treated for severe hypercalcemia.

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Deterrence/Prevention

See the list below:

  • Avoid prolonged bedrest for patients known to have rapid bone turnover.

  • Consider elective surgical procedures for patients with Paget disease after therapy has been initiated for calcium elevation. Mobilize patients as quickly as possible to minimize bone loss.

  • Worsening hypercalcemia is common in patients with known metastatic disease who are too ill to ambulate. This should be anticipated and treated before the patient becomes symptomatic.

  • Patients at risk for hypercalcemia should have scheduled appointments with ongoing evaluation to monitor for development or progression of the disease.

  • Avoid salt restriction, diuretics, and other causes of volume depletion and dehydration in patients with active or potential hypercalcemia.

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Prognosis

The prognosis of patients with hypercalcemia depends upon the etiology of the elevation.

  • Prognosis is very poor with malignancy that has progressed into development of hypercalcemia.

  • Prognosis is excellent when the underlying cause is treatable and treatment is initiated promptly.

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