Acute hypocalcaemia that is severe (<1.9 mmol/L) or symptomatic can be life-threatening and necessitates urgent treatment. It is often initially picked up when a patient has low ionised calcium on the blood gas as bone profiles are not routinely measured for every admission.
Contents
Symptoms & Signs
- Perioral & digital paraesthesia
- Positive Trousseu’s and Chvostek’s signs
- Tetany & carpopedal spasm
- Laryngospasm
- ECG changes: prolonged QT, bradycardia & other arrhythmias
- Seizure
Causes
- Total thyroidectomy (or parathyroidectomy) / hypoparathyroidism
- Severe Vitamin D deficiency
- Hypomagnesaemia (consider secondary to PPIs)
- Pancreatitis
- Rhabdomyolysis
- Drugs – loop diuretics, glucocorticoids, gentamicin, phosphates, theophylline, some cytotoxics
- Large volume blood transfusions
Investigations
- Bone Profile, U&Es, Magnesium, Vitamin D, PTH
- Consider amylase/lipase (pancreatitis) & creatine kinase (rhabdomyolysis) as clinically indicated
Treatment
You should use either your local guidelines or the guidelines produced by the Society for Endocrinology.
Mild (>1.9 mmol/L)
- Commence oral replacement using Sandocal (2 tablets BD) or Adcal (3 tablets BD) or any other available
- Treat the underlying cause e.g.:
- Stop causative drugs
- Vitamin D – load with around 300,000 units as per local guidelines
- Hypomagnesaemia – IV Magnesium (usually requires 24 mmol or 6g in 24h) & stop any precipitating drugs e.g. PPIs
- Thyroidectomy/Parathyroidectomy – may need 1-alpha hydroxylated Vitamin D. This should be started with specialist advice
Severe (<1.9 mmol/L or symptomatic)
- This is a medical emergency & should be treated whilst on a cardiac monitor
- Example regime could be:
- 10-20ml 10% calcium gluconate in 50-100ml of 5% dextrose over 10 minutes
- Calcium gluconate infusion – 100ml 10% calcium gluconate in 1L 0.9% saline/5% dextrose at 50-100ml/h
- Treat the underlying cause as above
- Ensure referral to the endocrinology team
References & Further Reading
- Society for Endocrinology Guidelines
- UK Medicines Information
- Hamilton, R.J., 2018. Tarascon adult emergency pocketbook. Jones & Bartlett Learning.
- Lewis III, J. L., 2018. Hypocalcemia. MSD Manual Professional Version.
- Turner, J., Gittoes, N., Selby, P. and Society for Endocrinology Clinical Committee, 2016. SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of acute hypocalcaemia in adult patients. Endocrine connections, 5(5), p.G7.
Written By Dr Akash Doshi (ST4)
Previous version by Dr Shoaib Hussain
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