Calcium disorders

Objectives

Guide the safe management of deranged calcium levels on Ops

Scope

Deployed care of high and low calcium 

Audience

Clinical decision makers R1 -R3

Initial Assessment & Management

Hypocalcaemia

Symptoms usually develop when adj calcium <1.9mmol/L (ionised <0.9 mmol/L)

Clinical features: are more severe if calcium fall is rapid

• Peri-oral and digital paraesthesia
• Positive Trousseau’s and Chvostek’s signs - 
• video link to performing above
• Tetany and carpopedal spasm
• Laryngospasm
• ECG changes (prolonged QT interval) and arrhythmia, bradycardia, hypotension
• Seizure
• CNS disturbance – irritability, confusion

Check adjusted serum calcium level. Normal range ionised 1.16–1.31 mmol/L (adjusted serum level 2.1-2.6 mmol/L

Is ionised calcium <0.9 (Adj serum <1.9) mmol/L - OR - Ionised >0.9 (adj serum >1.9) mmol/L AND signs/ symptoms of hypocalcaemia? 

YES  - Calcium chloride 10% in 10mL. Calcium chloride should be given by large bore peripheral IV, with monitoring for extravasation, or central line if available.  If time, to reduce hot flushes, bradycardia, hypotension or arrhythmias, 5ml of calcium chloride 10% can be diluted into 100ml 0.9% saline and infused over 10min with ECG monitoring.

Advanced Assessment & Management

Monitor serum calcium levels every 1-2 hours. In symptomatic patients a continuous infusion is often needed to prevent recurrence.

Assess cause:

• Pancreatitis (alcohol related/ gallstones)
• Rhabdomyolysis (endurance exercise)
• Large volume blood transfusions (trauma)
• Severe Vit D deficiency 
• Poisoning
• Neck surgery/ trauma
• Mg2+ deficiency (consider PPI-associated hypo­magnesaemia)

Hypercalcaemia

Investigations: (where available)

Ionized calcium (iStat) above normal range usually warrants treatment. Accuracy of ionised calcium to distinguish ‘high’ from ‘very high’ is not known. As soon as possible, obtain lab calcium (serum calcium, albumin, U&Es).

ECG – shortened QT interval and dysrhythmias indicative of severe hypercalcaemia

Treatment:

Rehydrate: IV 0.9% saline 4-6L in 24hrs  repeat fluids and continue monitoring 

• Discontinue diuretics
• Monitor for fluid overload

Refer to next role.

Second line – seek specialist input:

• Glucocorticoids e.g. hydrocortisone 100mg IV (only effective after 2-4 days).  These are only helpful when high calcium might be driven by too much active vitamin D; sarcoid/TB/Vit D overdose or lymphoma. For causes such as dehydration there would be no benefit. 

Prolonged Casualty Care