A couple weeks ago we discussed a case of a 41 yo man with a history of metastatic medullary thyroid cancer who was getting recurrently admitted for very severe hypocalcemia and hypokalemia. He presented to HUP after three previous admissions. In our ED he had a corrected calcium of of 6.2!
Let’s take a moment to review the management of acute hypocalcemia. Step one is to identify if the hypocalemia is SEVERE and would require immediate IV treatment. Severe hypocalcemia is defined by the presence of:
If these are present IV treatment is needed with calcium gluconate or calcium chloride. Calcium gluconate tends to be preferred as it is less caustic.
All of these patients should be started on oral calcium supplementation as well. You should be shooting for 500-1000mg of ELEMENTAL calcium every 8 hours. This is tricky, because the computer shows you the total weight of the compound and NOT just the calcium component.
Once the patient’s acute issue was managed we started to explore why he was having all of these worsened electrolyte abnormalities. Upon further history we learned that the patient has developed new diabetes, gained 10 pounds, and his calcitonin levels (used as a tumor marker) had been rising on outpatient checks. On exam he was noted to have multiple scattered bruises, a round face and striae. Endocrine was consulted to manage his calcium, but when they met him they became concerned for something else……. Cushing’s syndrome!