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Hypercalcemia and Cancer - Dr. Goldonowicz

5/1/2014

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Picture

Hypercalcemia
- Hypercalcemia relatively uncommon in the ED, but highly correlated with cancer and poor prognosis
     - 25% of cancer patients  
     - 50% die within a month of hypercalcemia dx

- Severe levels can be life threatening
     - Renal failure
     - Dysrhythmias
     - Coma
     - Death

- Occurs due to increased bone resorption and release of calcium
     - Bony mets release cytokines that break down bone
     - Tumors secrete PTHrP and an active form of Vitamin D, causing bone breakdown

- Who to suspect:
    - Elderly
    - Acute confusion/MS change
    - Unexplained weakness
    - History of cancer -- especially breast, lung, lymphoma, or multiple myeloma

- What to look for:
     - Neuropsych, GI and MSK  à vague symptoms

- Evaluate with serum calcium (must account for serum albumin and correct) or ionized calcium
     - Consider the clinical context and order additional labs/tests as necessary, including EKG and CXR

Treatment

Mild
  • <12mg/dL with no clinical findings (1.4-2mmol/L ionized)
  • Dispo home with close PCP/Oncology f/u
  • Stop any calcium supplements or calcium-sparing meds
  • Increase weight bearing activity and PO hydration

Moderate
  • 12-13.5mg/dL (2-2.5mmol/L ionized)
  • IVF with NS 200-300mL/hr until euvolemic à then keep UOP 100-150cc/hr
  • Loop diuretics only after volume repletion in pts with CHF or CKD
  • Touch base with Oncology; consider inpatient admission based on presentation

Severe
  • >13.5 with symptoms (2.5-3mmol/L ionized)
  • IVF as above
  • Calcitonin – 4IU/kg subQ or IM 
  • Bisphosphonates 
                   - Zoledronic acid – 4mg over 15 min
                   - Pamidronate – 60-90 mg over 2-24 hrs
  • Inpatient admission and call Oncology
  • Call Nephrology for emergent hemodialysis if:
                    - >13.5 with neuro sxs
                    - >18mg/dL
                    - Renal failure
                    - CHF


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  • RESIDENCY
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    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Fellowships at CMC
    • Ultrasound
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
  • PEOPLE
    • Program Leadership
    • Current Chiefs
    • PGY-3
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    • Recent Grads >
      • Class of 2023
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    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Incentive Shifts & Moonlighting >
      • AEC Incentive Shifts
      • STICU Moonlighting
      • MICU X moonlighting
      • Cardiac Rehab >
        • Pineville Cardiac Rehab
        • Union Cardiac Rehab
    • Schedules >
      • Block Schedule
      • ED Shift Schedule
      • Conference and Resident Lectures
      • Journal Club
      • CQR
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction
    • Off Service Rotators