This document discusses calcium imbalances, including hypercalcemia and hypocalcemia. It begins with introducing calcium, its functions, and homeostasis. Hypercalcemia is defined as a calcium level above 10.5 mg/dL and can be caused by primary hyperparathyroidism, malignancy, or excessive vitamin D and calcium supplementation. Clinical features of hypercalcemia include neurological, cardiovascular, and renal symptoms. Treatment involves rehydration, bisphosphonates, calcitonin, surgery for severe cases. Hypocalcemia is a calcium level below 8.5 mg/dL and can result from vitamin D deficiency, kidney disease, or certain drugs. Symptoms include numbness and tetany. Treatment focuses on calcium and

1. CALCIM IMBALANCES
PREPARED BY :
ANJALI NAUDIYAL
MSC(N) 1ST YEAR

2. GENRAL OBJECTIVE : AT the end of the presentation we would understand about
the calcium imbalances and their management.
SPECIFIC OBJECTIVE :
 Introduction to calcium its function and homeostasis .
 Define hypercalcaemia, hypocalcaemia and its causes.
 Explaining clinical features and diagnostic evaluations of calcium
imbalances .
 Describing the detailed management of calcium imbalances.
 Summarization of calcium imbalances.
 Conclusion of topic.
 References.

3. INTRODUCTION
Calcium is the most abundant metal and the fifth-most abundant element in the human body.Calcium is positively
charged ion (cation) which is 99% in bones and teeth, 1% in intracellular and 0.1% in extracellular fluid( blood and
interstitium)
Functions of calcium
 1.Biochemical functions 1. Development of bones and teeth : Calcium, along with phosphate, is required for the formation
and physical strength of skeletal tissue.
 2. 2. Muscle contraction : Ca2+ interacts with troponin C to trigger muscle contraction. Calcium also activates ATPase,
increases the interaction between actin and myosin.
 3. Blood coagulation : Several reactions in the cascade of blood clotting process are dependent on Ca2+(factor IV ).
 4. Nerve transmission: Ca2+ is necessary for the transmission of nerve impulse.
 5. Membrane integrity and permeability : Ca2+ influences the membrane structure and transport of water and several ions
across it.
 6. Activation of enzymes : Ca2+ is needed for the direct activation of enzymes such as lipase (pancreatic), ATPase and
succinate dehydrogenase
 8. Calcium as intracellular messenger
 9. Release of hormones
 10. Action on heart : Ca2+ acts on myocardium and prolongs systole

4. CALCIUM HOMEOSTASIS

6. HYPERCALCEMIA
Hypercalcemia is a total serum calcium concentration of > 10.5 mg/dL (> 2.62 mmol/L)
or ionized (free) calcium concentration of > 5.25 mg/dL (> 1.31 mmol/L).
Hypercalcemia affects 0.5% to 1% of the general population
ETIOLOGY
1. primary hyperparathyroidism: Primary hyperparathyroidism results from the
excessive secretion of PTH and typically produces frank hypercalcemia. Primary
hyperparathyroidism is approximately 2 to 3 times more common in women than in
men.
2. malignancy-associated hypercalcemia: It is most common in squamous cell
carcinoma of the lung, head, and neck, renal cell carcinoma, breast ca
3. Calcium & Vitamin D (Hypervitaminosis –D) over Supplementation
4. Sarcoidosis and Other granulomatous disorders
5. Cancer, multiple myeloma, and lymphoma, sarcoidosis.
6. Thyrotoxicosis, Adrenal Insufficiency.

7. 7. ENDOCRINE TUMORS: pheochromocytoma (may be associated with MEN-2), VIPomas.
8. Thiazide Diuretics & Indapamide
9. Hypervitaminosis A
10.Milk Alkali Syndrome (Rare nowadays)
11.Immobilization
12.Acute Renal Failure due to rhabdomyolyses
CLASSIFICATION OF HYPERCALCEMIA
According to level of corrected total serum calcium value hypercalcemia can be classified into:
1. Mild Hypercalcemia (>10.5 mg/dL to less than 12 mg/dL)
2. Moderate Hypercalcemia (Corrected Ca Level 12 to 14 mg/dL)
3. Severe Hypercalcemia (A level greater than 14 mg/Dl)

8. CLINICAL FEATURES
 Central nervous system effects: Lethargy, depression, psychosis, ataxia, stupor,
and coma
 Neuromuscular effects: Weakness, proximal myopathy, and hypertonia
 Cardiovascular effects: Hypertension, bradycardia (and eventually asystole), a
shortened QT interval (ECG)
 Renal effects: Stones, decreased GFR, polyuria, nephrocalcinosis;
 Gastrointestinal effects: Nausea, vomiting, constipation and anorexia
 Eye findings such as band keratopathy
 Systemic metastatic calcification.
 PNEUMONIC:

9. DIAGNOSTIC EVALUATIONS:
General Investigations:
S. Calcium Level
S. PO4 Level
S. Alkaline phosphate
S. Parathyroid level
S. Vitamin-D level
S. Total protein, S. Albumin
ECG
Specific Investigations: Varies according to cause.

10. TREATMENT MODALITIES
mild hypercalcemia
Patients with asymptomatic or mildly symptomatic hypercalcemia (calcium
<12 mg/dL) do not require immediate treatment.
However, they should be advised to avoid factors that can aggravate
hypercalcemia, including thiazide diuretics, volume depletion, prolonged
bed rest or inactivity, and a high calcium diet (>1000 mg/day).
Adequate hydration (at least six to eight glasses of water per day) is
recommended to minimize the risk of nephrolithiasis.

11. MODERATE HYPERCALCEMIA
In these patients, treatment with saline hydration and bisphosphonates.
SEVERE HYPERCALCEMIA
Patients with calcium >14 mg/dL (3.5 mmol/L) require more aggressive therapy.
Volume expansion with isotonic saline at an initial rate of 200 to 300 mL/hour to
maintain the urine output at 100 to 150 mL/hour. To maintain rehydration therapy.
loop diuretics can be given for calcium excretion.
Administration of salmon calcitonin (4 IU/kg) and repeat measurement of serum
calcium in after 6 hours. It can be repeated every 6 to 12 hours (4 to 8 IU/kg).
The concurrent administration of zoledronic acid(biphosphate) (ZA; 4 mg
intravenously [IV] over 15 minutes) or pamidronate (60 to 90 mg over two hours),
preferably ZA because it is superior to pamidronate in reversing hypercalcemia
to malignancy.
To increase GI excretion calcium patient can also be put on glucocorticoids
calcitriol production by the activated mononuclear cells in the lung and lymph nodes

12. Hemodialysis should be considered, in addition to the above treatments, in patients who have serum calcium concentrations in the
range of 18 to 20 mg/dL (4.5 to 5 mmol/L) and neurologic symptoms but a stable circulation or in those with severe hypercalcemia
complicated by renal failure.
Surgical management:
parathyroidectomy: removal of parathyroid gland.

13. Nursing responsibility
 Provide safety measures and institute seizure precautions, if appropriate.
 Give prescribed I.V. solution; ensure patent I.V. access.
 Expect to administer I.V. normal saline for severe hypercalcemia at an initial rate of 200 to 300 mL/hour,
and then adjust to maintain urine output at 100 to 150 mL /hour.
 Ensure readily available access to a bathroom if the patient is receiving I.V. saline.
 Assess for signs and symptoms of fluid overload.
 Assess for flu-like symptoms if the patient is receiving I.V. bisphosphonates.
 Administer I.M. or subcutaneous calcitonin every 12 hours, if ordered.
 Auscultate heart and lung sounds, noting signs and symptoms of heart failure.
 Institute continuous cardiac monitoring if patient exhibits ECG changes.
 Obtain specimens for laboratory testing, including serum calcium levels.
 Assess for signs and symptoms of hypocalcemia secondary to treatment.
 Assess level of orientation and note any changes.
 Prepare the patient and family for surgery, if indicated.

14. Hypocalcaemia
A decrease in the calcium levels below 8.5mg/dl is termed hypocalcemia,if serum protein is normal OR Ionized calcium <
4.5mg/dL
Etiology
• Vitamin D deficiency
• Chronic renal failure
• Magnesium deficiency
• Alcoholism
• Biphosphonate therapy - drugs used to treat high blood calcium levels or pills used to treat osteoporosis.
• Certain types of leukemia or blood disorders
• A complication of chemotherapy, tumor lysis syndrome, occurs when body breaks down tumor cells rapidly, after
chemotherapy. This may cause hypocalcemia, hyperkalemia,hyperuricemia, and other electrolyte abnormalities.
• Drugs such as diuretics, estrogens replacement therapy, fluorides, glucose, insulin, excessive laxative use, and
magnesium.
• Certain things in diet, like caffeine, phosphates (found in soda pop), and certain antibiotics may make it difficult for
to absorb calcium.

15. Pathophysiology
Decrease in extracellular Ca2*
The membrane potential on the outside becomes less negative
Less amount of depolarisation is required to initiate action potential
Increased excitability of muscle and nerve tissue

16. Clinical features
 "CATs go numb" - convulsions, arrhythmias, tetany, and numbness in the hands and feet and
around the mouth.
 Integumentary : Petechiae purpura paresthesias, tingling or 'pins and needles' sensation in and
around the mouth and lips, and in the extremities of the hands and feet.
 Muscoskeletal : Carpopedal and generalized tetany
Trousseau sign (eliciting carpal spasm by inflating the blood pressure cuff and maintaining the cuff
pressure above systolic)
Chvostek's sign (tapping of the inferior portion of the zygomatic bone will produce facial spasms)
Tendon reflexes are hyperactive
 Cardiovascular system: Effects on cardiac output
• Negative chronotropic effect, or a decrease in heart rate.
• Negative inotropic effect, or a decrease in contractility
iintermittent QT prolongation,

17. Diagnostic evaluation
 History collection and physical examination
S. Calcium and Phosphate levels
• S. Albumin
• S. & Urinary Creatinine (for renal disease)
• PTH levels in serum
• Parathyroid antibodies (present in idiopathic hypoparathyroidism)
•Vitamin D serum level (low inVitamin D def.)
• Magnesium level
• X-rays of metacarpals (showing short 4th metacarpals which occur in pseudo
hypoparathyroidism)
• ECG

18. management
 1. Dependent on the underlying cause and severity
 2. Administration of calcium alone is only transiently effective.
 3. Mild/moderate asymptomatic cases: Often adequate to increase dietary
calcium by 1000 mg/day
 Aim to keep serum Ca between 8-8.5mg/dl
 Oral Calcium supplements
 • Active preparations ofVitamin D • 1,25-dihydroxyvitamin D (Calcitriol)
• 1-α-hydroxyvitamin D (Alfacalcidiol)
@ 50 nanograms/kg (Max ~2 micrograms/day
 Severe Symptomatic: • IV 10% Calcium Gluconate 10 ml over 10 minutes •
Continuous IV infusion of Calcium Gluconate @ 0.1 mmol/kg over 24 hours .

19. SUMMARY
 Hypercalcemia is an elevated serum ionized calcium or total calcium concentration,
corrected for albumin. There are five major differential diagnostic techniques of
hypercalcemia by: (1) endocrine diseases, (2) malignancy, (3) granulomatous diseases, (4)
drug induced and (5) miscellaneous. The most common etiology in hospitalized patients is
malignancy, and in ambulatory patients it is primary hyperparathyroidism. These two
diagnostic categories account for more than 90% of cases of hypercalcemia. The clinical
findings of hypercalcemia are also mentioned— such as neuromuscular manifestations,
cardiovascular manifestations, renal manifestations, and so on. The laboratory testing
guided by the history and physical status of the patient are important to establish the correct
diagnosis and the severity of illness. The proposed treatments of hypercalcemia includes:
dialysis against a low-calcium bath, use of calcitonin, hydrate with normal saline infusion,
measures to rapidly reduce the serum calcium, and use of glucocorticoids.

20.  Hypocalcemia can occur acutely over minutes to hours or chronically
over weeks to months. Correspondingly, the signs and symptoms of
hypocalcemia can develop acutely or chronically and can be life-
threatening. The clinical manifestations of hypocalcemia are due to the
increased neuromuscular tingling in the extremities and around the
mouth. Chvostek’s and Trousseau’s signs can be elicited. When severe,
tetany, convulsions, laryngospasm and bronchospasm can occur.
Hypocalcemia symptoms are a result of both the absolute level of serum
calcium and the rate of change in serum calcium concentration.
Management consists of calcium supplementation and identifying and
treating the underlying cause.

21. CONCLUSION
 I concluded that hypercalcemia and hypocalcemia can be serious if left untreated. It is
therefore important that patients with cancer are closely monitored and receive adequate
prevention and treatment measures to maintain normal blood calcium levels.Even the
normal individual should also adequate sunlight for vitamin D and due to their lifestyle busy
schedule if not possible then go for the investigation of vitamin D and start supplement after
concerning to physician.

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 6. www. Wikipedia.com

23. THANKYOU