case 1
DESCRIPTION
Case 1. 53F presents to ED with dysuria PMHx: HTN, Hyperlipidemia, UTI is diagnosed and oral Abx script given Getting ready for discharge, but on routine labs you notice Ca2+= 3.3 mmol/L On further history the patient states she has no symptoms and has been otherwise well. - PowerPoint PPT PresentationTRANSCRIPT
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Case 1 53F presents to ED with dysuria
PMHx: HTN, Hyperlipidemia,
UTI is diagnosed and oral Abx script given
Getting ready for discharge, but on routine labs you notice Ca2+= 3.3 mmol/L
On further history the patient states she has no symptoms and has been otherwise well.
Management? Disposition?
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Case 2 70M with known Lung CA, presents with
acute psychosis and Ca= 3.4 mmol/L
Management?
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Hypercalcemia
Lab RoundsSultana Qureshi, PGY-2August 3, 2006
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Calcium Metabolism
Hormone Effect on bones Effect on gut Effect on kidneys
Parathyroid hormone Ca++, PO4 levels in blood
Supports osteoclast resorption
Increases absorption via Vit D
Supports Ca++ resorption and PO4 excretion, activates 1-hydroxylation
Vit D Ca++, PO4 levels in blood
- Ca++ and PO4
absorption -
Calcitonin Ca++, PO4 levels in blood
when hypercalcemia is present
Inhibits osteoclast resorption
- Promotes Ca++ and PO4 excretion
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Definition
Total Corrected Serum Ca2+ >2.62 mmol/L
OR Ionized Ca2+ > 1.35 mmol/L
Corrected = measured Ca2+ + 0.02 (40-albumin)
Or for every ↓5 of albumin, add 0.1 to serum Ca
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Symptoms“Bones, Stones, Groans, Moans”
General Weakness, malaise,
dehydration Skeletal (Bones)
Bone pain Fractures/Deformities
GI (Groans) Constipation Abdo pain Anorexia & W.L., NV PUD, pancreatitis
Cardiovascular Dysrhythmias ECG changes HTN, vascular calcification
Renal (Stones) Nephrolithiasis Polyuria, polydipsia, nocturia Nephrogenic DI Renal failure
Neurologic Hypotonia, Hyporefelxia, ataxia Myopathy Paresis Altered LOC/Coma
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Symptoms (cont’d)“Bones, Stones, Groans, Moans”
Psychiatric (Moans)
> 3mmol/L Increased alertness Anxiety/Depression Cognitive Dysfunction Organic Brain Syndromes
> 4mmol/L Psychosis
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ECG
Changes:
-shortening of QT
-prolongation of PR
-ST depressions
U- waves
Severe:
-bradyarrythmias
-BBB and high AV block
-potentiates Digoxin effects
-Cardiac Arrest
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Causes
90% of cases due to Primary Hyperparathyroidism (30-50%)
25-75/100 000 (US) mcc Parathyroid adenoma Usually mild hyperCa High PTH
Malignancy (40%) 20-30% of Cancer patients Poor prognosis – 1 yr survival = 10-30% Lung/Breast/Kidney/Myeloma/Leukemia More likely to be encountered in ED Low PTH 2 mechanisms: PTHrP or osteolytic
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Other common causes
Iatrogenic/DrugsThiazidesLithiumHypervitaminosis A & D
Granulomatous DiseaseSarcoidosisTuberculosis
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Other less common causes:
Parathyroid hormone-related Sporadic, familial, associated with multiple endocrine neoplasia I or II Tertiary hyperparathyroidism Associated with chronic renal failure or vitamin D deficiency Vitamin D-related Vitamin D intoxication Usually 25-hydroxyvitamin D2 in over-the-counter supplements Hodgkin's lymphoma Genetic disorders Familial hypocalciuric hypercalcemia: mutated calcium-sensing receptor
Medications Milk-alkali syndrome (from calcium antacids) Other endocrine disorders Hyperthyroidism Adrenal insufficiency Acromegaly Pheochromocytoma Other Immobilization, with high bone turnover (e.g., Paget's disease, bedridden child) Recovery phase of rhabdomyolysis
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Who needs immediate ED treatment?
Ca > 3.5 mmol/L
Ca > 3 mmol/L with symptoms
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Management
Four Goals
1) Correct Hypovolemia
2) Increase renal calcium excretion
3) Reduce osteoclastic activity
4) Treat primary disorder
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Management
1) Correct Hypovolemia Decreases Ca by 0.4 - 0.6 Increases GFR & Na load to kidneys, thus Ca excretion Various recommendations
NS IV @ 200-300cc/hr. Usually require 2-4L per day X 1-3 days. Aim for U/O of 200 cc/hr
Caution with elderly, poor LV function Also, correct co-existing electrolyte abnormalities
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Management
2) Increase renal calcium excretionCorrecting HypovolemiaLasix 10-40 mg IV q6-8h Dialysis in patients with renal failure
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Management 3) Reduce osteoclastic activity
Bisphosphonates Pamidronate 60-90 mg IV over 4 hours Max effect in 72 hours More effective in hyperCa of malignancy
Calcitonin In severe cases, 4 un/kg SQ q6h Starts working with a few hours
Glucocorticoids In Vit D mediated hyperCa (Vit D intoxication, hematologic
malignancies, Granulomatous disease) Hydrocortisone 200-300mg IV qd X 3 days
Mythramycin, Gallium Nitrate, IV phosphate – no longer used
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Case 1 53F presents to ED with dysuria
PMHx: HTN, Hyperlipidemia,
UTI is diagnosed and oral Abx script given
Getting ready for discharge, but on routine labs you notice Ca2+= 3.3 mmol/L
On further history the patient states she has no symptoms and has been otherwise well.
Management?
![Page 21: Case 1](https://reader033.vdocuments.us/reader033/viewer/2022051621/5681474a550346895db489e8/html5/thumbnails/21.jpg)
Case 2 70M with known Lung CA, presents with
acute psychosis and Ca= 3.4 mmol/L
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The End