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.
Emergency Department Care
The treatment of hypercalcemia depends on the level, the clinical presentation, and (if known) 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.
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Initial goals of treatment
Assessment and maintenance of airway, breathing, and circulation (ABCs)
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)
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The initial step in the care of severely hypercalcemic patients is hydration and forced calciuresis. Because most of these patients are profoundly dehydrated, 0.9 normal saline is the crystalloid of choice for rehydration. 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 [7] :
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.
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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.
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Bisphosphates - These agents will inhibit osteoclast activity for up to a month. However, these agents may take 48-72 hours before reaching full therapeutic effect. [7]
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, [23] 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.
