Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Hypocalcemia and Hypercalcemia

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In one line

·Calcium keeps muscles and nerves firing smoothly; when it's off, everything from your heartbeat to your brain misfires.

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Normal physiology

·Calcium floats in your blood at a steady level, held there by two main controllers: parathyroid hormone (PTH) from four tiny parathyroid glands tucked behind your thyroid, and active vitamin D made by your kidneys. These two work like a thermostat, pulling calcium out of bone, saving it in the kidneys, and helping your gut absorb it from food so nerves and muscles always have the exact amount they need to fire.

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What goes wrong

·Calcium goes wrong when the controllers break or when something floods or drains the system faster than the controllers can adjust.

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Hallmark signs

·Muscle cramps and twitching (tetany)
·Tingling or numbness around the mouth, fingers, and toes (paresthesias)
·Chvostek sign (face twitches when you tap the cheek)
·Trousseau sign (hand cramps when a blood pressure cuff is inflated)
·Seizures
·Long QT interval on ECG (heart rhythm change)
·Confusion or memory trouble
·Weak, brittle bones or bone pain (in chronic low calcium (hypocalcemia))

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Red flags · escalate now

·Seizure or severe muscle spasms that won't stop
·Chest pain, fast heartbeat, or fainting (signs the heart rhythm may be dangerous)
·Severe confusion, trouble waking up, or coma
·Very high calcium (above 14 mg/dL) or very low calcium (below 7 mg/dL with symptoms)
·Sudden severe belly pain, vomiting, or signs of pancreatitis (which high calcium can trigger)

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Workup

·Serum calcium — total and ionized (free) calcium
·Serum albumin
·Parathyroid hormone (PTH) — intact PTH
·25-hydroxyvitamin D — the storage form of vitamin D
·Serum magnesium
·Serum phosphate
·Serum creatinine and estimated GFR (eGFR)
·Electrocardiogram (ECG)

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Treatment

·IV calcium gluconate — 1–2 grams (10–20 mL of 10% solution) diluted in 50–100 mL normal saline, given over 10–20 minutes
·IV magnesium sulfate — 1–2 grams (2–4 mL of 50% solution) IV over 15 minutes, or oral magnesium oxide 400 mg twice daily if not urgent
·Oral calcium carbonate or calcium citrate — 1–2 grams elemental calcium daily in divided doses (e.g. 500 mg three times daily with meals)
·Active vitamin D — calcitriol 0.25–0.5 mcg by mouth twice daily, or ergocalciferol (vitamin D2) 50,000 units weekly if deficiency is the cause
·IV normal saline — 200–300 mL/hour for several liters, then loop diuretic furosemide 20–40 mg IV once volume is restored
·Calcitonin — 4 units/kg IV or IM every 12 hours
·Bisphosphonate — zoledronic acid 4 mg IV over 15 minutes, or pamidronate 60–90 mg IV over 2–4 hours

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NCLEX trap

·Muscle cramps in low calcium (hypocalcemia) come from low calcium, not low potassium. The nerves are firing too much because calcium usually keeps them calm. Give calcium, not potassium. Check both levels, but they solve different problems.
·Low albumin (a blood protein) can drag down total calcium without lowering ionized calcium — the free-floating part that actually does the work. Always measure ionized calcium or correct the total calcium for albumin. The total can lie if albumin is off.
·In low calcium (hypocalcemia), confusion happens because the brain does not have enough calcium to work right. It is not a separate problem. Fix the calcium first. Sedatives hide the danger, slow you down, and can make things worse.
·Low calcium (Hypocalcemia) can make the muscles around the voice box squeeze shut and cause a high-pitched noise on breathing in (stridor) — a high-pitched, loud breathing sound. This is a life-threatening emergency that can block the airway. Do not assume one normal calcium rules it out. Check ionized calcium, check magnesium, and repeat labs. A high-pitched noise on breathing in means get ready to protect the airway right now.
·A long QT interval in low calcium (hypocalcemia) means the heart's electrical recovery is taking too long. This is not cosmetic. It puts the heart at risk for a deadly rhythm called torsades de pointes. Treat the low calcium urgently.
·If the patient is seizing, has a high-pitched noise on breathing in (stridor), has a dangerously long QT, or shows other critical signs, you need IV calcium gluconate right now. Oral calcium takes hours to days to work — far too slow for an emergency. Match the route to how sick the patient is.

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