Shout out to Ben Slovis for providing this case.

 

22F s/p thyroidectomy here with 1 day back pain and generalized weakness.  Patient’s thyroidectomy was complicated by inadvertent parathyroidectomy, and never followed-up to manage this complication.  On exam, no concerning signs for cord compression, but significant paralumbar muscle spasms. Her EKG demonstrates a QTc of 668.  Her total serum calcium results at 4.9 mg/dL.  You have the patient put on a cardiac monitor. It’s a Tuesday. There are 30 boarded patients. You know this patient will be in the ED all day awaiting a tele bed.  How do you want to manage her hypocalcemia?

 

 

 

 

IV calcium preparations last 30 min – 2 hours.  Give 1g of calcium gluconate q1-2 hours for a total of 3 doses. Reassess the situation. Still symptomatic? How’s the QT? Check an ionized calcium on blood gas. If the patient needs more calcium, then start an infusion. Give 5-10g of calcium gluconate in 1L of D5W infused at rate 30 to 100 ml/hr.

You can also start the patient on oral calcium and a vitamin D supplement. The IV treatments are basically a bridge to homeostasis with PO calcium. The inpatient team will be doing this; you can be a star and initiate treatment in the ED.

Also, check that magnesium level. If low, your patient isn’t going to respond to calcium repletion. Give mag concurrently (if not before) the calcium.