Hypercalcemia (Elevated Calcium)

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Hypercalcemia 

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Hypercalcemia 
Mild hypercalcemia: 10.5 to 11.9 mg/dL 
Moderate hypercalcemia: 12.0 to 13.9 mg/dL
Hypercalcemic crisis: 14.0 to 16.0 mg/dL
-Obtain serum albumin level and ionized Ca level.
-Correct for Ca with albumin.
-Will discontinue thiazide diuretics or lithium medications, encourage PO intake.
-Will reserve treatment for symptomatic or severe hypercalcemia >14mg/dL.
-Will obtain serum PTH, if elevated, will stop workup as this is likely primary hyperparathyroidism.
-If PTH level is normal, will obtain Urinary Calcium excretion to exclude familial hypocalciuric hypercalcemia.
-If PTH level is low, will obtain TSH, Vitamin D, Phosphorus, Magnesium, Alkaline Phosphatase levels, UPEP with immunofixation, renal functions, and urinary calcium-creatinine ratio.
-EKG to monitor for T wave flattening or inversion, QRS/PR prolongation and ST elevation.
-CXR + CT to rule out sarcoidosis, lung cancer and renal cancer. Will need mammogram to rule out breast cancer. Will also obtain Ultrasound + MRI of parathyroid gland. 
-If suspecting malignancy, will order a bone scan. Will need a bone survey if concerned for multiple myeloma.
-Fluid resuscitation with 2x maintenance rate normal saline.
-Will need urgent hemodialysis if comorbid heart failure or renal insufficiency.
-Will administer Calcitonin, Bisphosphonates & Glucocorticoids. 
-If labs show hyperparathyroidism, will need sestamibi parathyroid scan +/- surgery evaluation.
-Monitor for change in mental status/deterioration.
-Poor prognosis in setting of malignancy. Up to 50% 30 day mortality.