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AIP: Acute confusional state > Hyper/hypocalcaemia > Flashcards

Hyper/hypocalcaemia Flashcards

1
Q

What are 13 causes of hypercalcaemia? (first 5 are key)

A
  1. Primary hyperparathyroidism
  2. Tertiary hyperparathyroidism
  3. Malignancy
  4. Osteolytic bone lesions
  5. Humoural hypecalcaemia (tumour derived PTHrP)
  6. Granulomatous disease (sarcoid, TB)
  7. Vitamin D
  8. Vitamin A
  9. Lithium
  10. Thiazides
  11. Thyrotoxicosis
  12. Milk-Alkali syndrome
  13. Familial hypocalcuric hypercalcaemia
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2
Q

What are 5 investigations that should be performed in the hypercalcaemic patient?

A
  1. ECG
  2. LFTs
  3. U+Es
  4. Bone profile (calcium, phosphate, albumin, total protein, ALP)
  5. PTH (parathyroid hormone) measurement
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3
Q

What are 5 things that form part of a bone profile?

A
  1. Calcium Calcium
  2. Phosphate
  3. Albumin
  4. Total protein
  5. ALP
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4
Q

What are 5 additional investigations to perform in suspected myeloma?

A
  1. Urinary Bence-Jones proteins
  2. Plasma electrophoresis
  3. FBC
  4. Chest x-ray
  5. Bone scan/PET scan
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5
Q

What is an important additional investigation to perform in suspected familial hypocalciuric hypercalcaemia?

A

24-hour urinary calcium

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6
Q

What further imaging would you perform in hypercalcaemia if you suspect primary hyperparathyroidism as the cause?

A

USS neck

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7
Q

What are 3 aspects of the immediate management of acute hypercalcaemia?

A
  1. Aggressive IV fluids - normal saline, 3-4L/day
  2. Bisphosphonates
  3. Management to prevent recurrent depending on cause, e.g. chemo, resection, radiotherapy, steroids, calcitonin, furosemide
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8
Q

Why are IV fluids given in hypercalcaemia?

A

corrects dehydration, protects the kidneys and increases calcium excretion

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9
Q

What IV fluid therapy is given in hypercalcaemia?

A

3-4L per day of normal saline

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10
Q

What is the mechanism of action of bisphosphonates to treat hypercalcaemia?

A

inhibit osteoclast activity, reducing calcium release from bones

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11
Q

How long do bisphosphonates typically take to work to lower calcium and when is the maximal effect?

A
  • take 2-3 days to work
  • maximal effect being seen at 7 days
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12
Q

What is an alternative drug to bisphosphonates which may be used instead of them and why?

A

calcitonin - quicker effect than bisphosphonates

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13
Q

What is the management when sarcoidosis is the cause of hypercalcaemia?

A

steroids

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14
Q

When are loop diuretics such as furosemide used in hypercalcaemia?

A

patients who cannot tolerate aggressive fluid rehydration

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15
Q

Why should loop diuretics be used with caution in hypercalcaemia?

A

may worsen electrolyte derangement and volume depletion

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16
Q

What is the commonest cause of primary hyperparathyroidism in non-hospitalised patients?

A

primary hyperparathyroidism

17
Q

What is the commonest cause of hypercalcaemia in hospitalised patients?

A

malignancy

18
Q

What are 3 examples of processes in malignancy that can cause hypercalcaemia?

A
  1. Bone metastases
  2. Myeloma
  3. PTHrP from squamous cell lung cancer
19
Q

What are the 4 key features of hypercalcaemia?

A
  • bone pain
  • urinary tract stones
  • abdominal pain
  • psychiatric problems e.g. confusion

bones, stones, groans and moans

20
Q

What is the key ECG features of hypercalcaemia?

A

shortened QT interval

21
Q

What is the effect of hypercalcaemia on blood pressure?

A

causes hypertension

22
Q

What is the definition of hypocalcaemia?

A

state of electrolyte imbalance in which the circulating serum calcium level is <2.1 mmol/L

23
Q

What are 6 causes of hypocalcaemia?

A
  1. Vitamin D deficiency
  2. Hypoparathyroidism
  3. Hyperphosphataemia
  4. Acute pancreatitis
  5. Hypomagnesaemia
  6. Acute alkalosis
24
Q

What are 3 causes of vitamin D deficiency?

A
  1. Malnutrition (i.e. osteomalacia)
  2. Malabsorption (e.g. gastrectomy, short bowel syndrome, Coeliac disease, chronic pancreatitis)
  3. CKD
25
Q

What are 3 causes of hypoparathyroidism?

A
  1. Post-parathyroidectomy
  2. Inherited
  3. Pseudohypoparathyroidism
26
Q

What are 3 causes of hyperphosphataemia (that can cause hypocalcaemia)?

A
  1. Tumour lysis syndrome
  2. Rhabdomyolysis
  3. Phosphate administration
27
Q

What is the mnemonic to remember the clinical features of hypocalcaemia?

A

SPASMODIC

  • S: spasm (Trousseau’s sign)
  • P: perioral paraesthesia
  • A: anxiety/irritability
  • S: seizures
  • M: muscle tone increase (colic, dysphagia)
  • O: orientation impairment (i.e. confusion)
  • D: dermatitis
  • I: impetigo herpetiformis
  • C: Chvostek’s sign
28
Q

What is the Trousseau’s sign?

A

inflate BP cuff, occlude arterial flow to hand for 3-5 min

carpopedal spasm: flexion at wrists, MCP joints, extension of IP joints, adduction of thumbs/fingers

29
Q

What is Chvostek’s sign?

A

contraction of ipsilateral facial muscles elicited by tapping facial nerve anterior to ear

positive response = twitching of lip to spasm all of facial muscles

30
Q

What are 7 investigations to perform in hypocalcaemia?

A
  1. ECG - arrhythmia
  2. Bone profile (calcium, phosphate, albumin, total protein, ALP)
  3. PTH
  4. Magnesium
  5. Vitamin D
  6. Amylase (if suspected pancreatitis)
  7. X-rays (if suspected osteomalacia)
31
Q

What are the 2 key signs (not that frequently used) of hypocalcaemia?

A
  1. Trousseau’s sign
  2. Chvostek’s sign
32
Q

What is the key ECG sign of hypocalcaemia?

A

prolonged QT interval

33
Q

What are 2 signs of chronic hypocalcaemia?

A
  1. Depression
  2. Cataracts
34
Q

What can give falsely low calcium levels?

A

contamination of blood samples with EDTA

35
Q

What is the acute management of severe hypocalcaemia?

A

IV replacement - preferred method is IV calcium gluconate, 10ml of 10% solution over 10 minutes

36
Q

What monitoring is recommended in hypocalcaemia?

A

ECG - due to prolonged QT interval

37
Q

What is the management of mild hypocalcaemia?

A

oral calcium supplementation

38
Q

What constitutes severe hypocalcaemia (needing IV calcium gluconate)?

A

spasms or ECG changes

39
Q

What are 5 aspects of long-term management of hypocalcaemia?

A
  1. Treat cause
  2. Encourage good dietary calcim and vitamin D intake
  3. Calcium and vitamin D supplementation
  4. Alphacalciferol if CKD
  5. Magnesium supplements if concurrent hypomagnesaemia

AIP: Acute confusional state (14 decks)

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