A 62-year-old woman presents with an altered mental status. She is responsive to painful stimuli and has a Glasgow Coma Scale score of 11. Blood pressure is 100/60 mm Hg and heart rate is 100/min. Physical examination reveals poor skin turgor and dry mucus membranes. EKG shows QT interval shortening. Laboratory findings are serum calcium 14.2 mg/dL, serum phosphorus 2.9 mg/dL, serum potassium 3.9 mEq/L, and creatinine 1.9 mg/dL. Your initial treatment should include:
Magnesium sulfate 2 gm slow IV push.
Pamidronate 60 mg IV.
Calcitonin 4 IU/kg.
Furosemide 60 mg IV after saline resuscitation.
The initial treatment of choice in this patient with severe hypercalcemia and dehydration is aggressive administration of saline and furosemide diuresis. Subsequent therapy is dictated by the cause and severity. The biphosphonates (pamidronate) and calcitonin are also effective in treating hypercalcemia, but they are usually not used in the ED, and would not be instituted until after the patient is rehydrated with IV fluids. Patients with renal failure and hypercalcemia may require dialysis.