A 55-year-old male patient arrives to the emergency department complaining of worsening fatigue, vomiting, and weight loss over the last 2 weeks. A basic metabolic panel demonstrates the following:
What is the best next step in management?
A. Aggressive fluid bolus of 0.9% NaClCorrect Answer: A
Hypercalcemic crisis, or severe hypercalcemia, is a life-threatening emergency often in the setting of malignancy, primary hyperparathyroidism, or medication use. Patients may exhibit a variety of symptoms including neurologic, gastrointestinal, and renal manifestations of hypercalcemia, particularly dehydration. Immediate attention and management is crucial. The first step should be aggressive intravenous rehydration with normal saline at 200 to 300 mL/h, then adjusted to maintain urine output at 100 to 150 mL/h.
Once resuscitation is initiated, management should be focused on promoting urinary excretion of calcium and to identify the underlying cause of hypercalcemia. Calcitonin (4 IU/kg), pamidronate (60-90 mg over 2 hours), or zoledronic acid (4 mg over 15 minutes) can further prevent bone resorption and stabilize serum calcium levels. These medications may take some time to exert their effect (calcitonin 12-48 hours, bisphosphonates 24- 96 hours) and should be administered quickly. Furosemide increases urinary calcium excretion and should be administered only when the patient is in a euvolemic state. For hypercalcemia unresponsive to other measures, mithramycin should be administered. Hemodialysis should be reserved for severely symptomatic patients or those who do not demonstrate a reduction in calcium levels after the above treatments have been initiated.
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