HWN Suggests

The Calcium Quandary

Hypocalcemia’s manifestations range from asymptomatic to life threatening. Serious physiologic derangements are typically not seen until ionized calcium levels fall below 1.6 mEq/L, but with rapid declines symptoms may be seen at higher levels. Causes of acute, severe deficiency include shock, sepsis, pancreatitis, drug toxicities, parathyroidectomy or neck surgeries causing ischemia to the parathyroid tissues and hyperphosphatemia – typically in the setting of rhabdomyolysis or tumor lysis syndrome. In mild chronic cases, oral therapy will usually suffice, so consider reserving your IV calcium for cases with acute causes or those with severe symptoms such as seizure, heart failure or altered…

read full article

Featured

 Don't Forget the Calcium (in Trauma)

Complications of massive transfusion include electrolyte derangements, with hypocalcemia being one of the main clinically significant electrolyte abnormalities. Studies show that over half of trauma patients are hypocalcemic prior to receiving any blood product on arrival to the emergency department. Hypocalcemia contributes to coagulopathy, which may lead to continued blood loss and possibly death.

 Hypocalcemia and Neonates

Neonates are particularly at risk for hypocalcemia...

 Podcast 186.0: Hypocalcemia

A quick primer on hypocalcemia in the ED... Hypocalcemia Repletion: * IV calcium supplementation with 100-300 mg Ca2+ raises serum Ca2+ by 0.5 – 1.5 mEq * For acute but mild symptomatic hypocalcemia: 200-1000mg calcium chloride IV or 1-2g IV calcium gluconate over 2 hours * For severe hypocalcemia: 1g calcium chloride IV or 1-2g IV calcium gluconate IV over 10 minutes repeated q 60 min until symptoms resolve.

Articles of Interest

The Clutch Hypocalcemia Podcast

In this short, but ultra HY podcast, I discuss the vast majority of what you need to know in relation to hypocalcemia for your USMLE exams. I spend a lot of time discussing mechanisms, pathophysiology, treatments, diagnostic approaches, and other key exam details.

Answers to all the Questions You Didn't Know You Had About Hypocalcemia

Recorded at the Maine Medical Center Emergency Medicine Residency Grand Rounds in September, 2021.

Calcium Gluconate Versus Calcium Chloride for the Treatment of Hypocalcemia

Calcium gluconate and calcium chloride are two commonly used compounds for correction of hypocalcemia. Concern over tissue necrosis with the use of calcium chloride may preclude its use in these cases, but the delayed rise in serum calcium in calcium gluconate may preclude its use.

Caustic Hypocalcemia: Hydrofluoric Acid Burn

Regional intravenous perfusion of calcium gluconate for the treatment of digital HF burns has been reported

CORE EM: Hypocalcemia

Ionized calcium < 2.0 mEq/L - More accurate assessment as no correction required.

EM@3AM: Hyper- and HypoCa

IV calcium is indicated if patient is symptomatic and ionized Ca <1 mmol/L. Give 10% calcium chloride 10 mL or 10% calcium gluconate 10-30 mL over 20 minutes. Can repeat until symptoms resolve or initiate an infusion of 10% calcium chloride .02 to .08 mL/kg/h. Magnesium will need to be replaced along with calcium.

Hypocalcaemia, Trauma and Major Transfusion. St Emlyn’s

I think the time has come for us to consider giving a bolus of calcium chloride alongside the first unit of blood in the patient with traumatic haemorrhage. This intervention is low cost, easy to administer, already present in the drug packs of prehospital teams, and, although not directly studied yet, the potential benefits far outweigh the potential harm.

Hypocalcemia

Severe (symptomatic, QT prolongation) Calcium gluconate 1-2g IV in 50mL of D5W over 10-20min followed by slow infusion of additional 2g over 2 hours.

Hypocalcemia in Trauma

Hypocalcemia during massive transfusion could actually be seen as an inadvertent iatrogenic process. Serum calcium is chelated due to the citrate used as a preservative in the Packed Red Blood Cells (PRBC’s), Fresh Frozen Plasma (FFP), and even the Liquid Never-Frozen Plasma we use in our Med Flight blood coolers.

The COCA Trial – Calcium in Cardiac Arrest

Administration of calcium compared to saline did not result in a statistically significant difference in sustained ROSC for adult patients with OHCA.

Resources

EM in 5

Video...

EMCrit

Calcium should be checked if there is clinical suspicion for hypocalcemia (e.g., massive transfusion, arrhythmia, seizure, general electrolytic disarray).

Life in the Fastlane

Causes: Metabolic alkalosis – citrate toxicity. Metabolic acidosis – acute renal failure, tumour lysis, rhabdomyolysis, pancreatitis, ethylene glycol poisoning, hydrofluoric acid, sepsis, burns.

WikEM

Avoid empiric treatment in patients taking digoxin due to risk for Stone Heart...