Perform ABCDE assessment.
Assess hydration status and fluid balance.
Check for neurological symptoms:
- Confusion
- Lethargy
- Delirium
- Reduced GCS
Look for dehydration signs:
- Dry mucous membranes
- Tachycardia
- Postural hypotension
Record baseline observations and urine output.
Perform ECG monitoring.

Typical ECG finding:

Short QT interval
Occasionally heart block or ventricular arrhythmias

2️⃣ Confirm the Diagnosis

Check albumin-adjusted serum calcium.
Repeat calcium if unexpected or borderline.
Assess severity category to guide urgency of treatment.

3️⃣ First-Line Treatment – Volume Expansion

💧 Start IV 0.9% saline.
Typical replacement:
- 2–4 litres within the first 24 hours
- Adjust according to age, renal function, and heart failure risk
Aim to restore intravascular volume and promote renal calcium excretion.
Monitor:
- Fluid balance
- Urine output
- Daily weights if needed

Important:

Loop diuretics should NOT be used routinely.
They may be used only if fluid overload develops.

4️⃣ Investigate the Underlying Cause

The most important early investigation is parathyroid hormone (PTH).

🧪 Blood tests:
- Corrected calcium
- Urea and electrolytes
- Phosphate
- Parathyroid hormone (PTH)
- Vitamin D level
- ALP
- FBC
- ESR or CRP
🔬 Myeloma screen:
- Serum electrophoresis
- Urine Bence Jones protein
🫁 Imaging if malignancy suspected:
- Chest X-ray
- CT scan where indicated

PTH interpretation:

⬆️ Calcium + ⬆️ or normal PTH → Primary hyperparathyroidism
⬆️ Calcium + ⬇️ PTH → Malignancy, vitamin D excess, granulomatous disease

5️⃣ Second-Line Treatment – Anti-resorptive Therapy

💉 Give an IV bisphosphonate once the patient is adequately hydrated.
Common options:
- Zoledronic acid 4 mg IV over ~15 minutes
- Pamidronate 60–90 mg IV over 2–4 hours
Effects:
- Onset: 24–48 hours
- Peak calcium reduction: 4–7 days
Use with caution in renal impairment.

6️⃣ Additional Therapies (Selected Cases)

Calcitonin
- Produces rapid calcium reduction
- Effect begins within hours
- Short-lived (tachyphylaxis occurs)
Glucocorticoids
- Useful in:
- Sarcoidosis
- Lymphoma
- Vitamin D intoxication
Denosumab
- Used in bisphosphonate-resistant malignancy-associated hypercalcaemia
- Also useful in severe renal impairment

7️⃣ Management of Severe or Refractory Hypercalcaemia

Consider dialysis if:
- Severe hypercalcaemia (>3.5–4 mmol/L)
- Renal failure
- Fluid overload preventing hydration
Seek urgent specialist input:
- Endocrinology
- Oncology
- Renal team

8️⃣ Definitive Treatment

Management ultimately depends on the underlying cause.
Common treatments include:
- Parathyroidectomy for primary hyperparathyroidism
- Oncological therapy for malignancy
- Steroids for granulomatous disease
- Stopping causative drugs (e.g. thiazides, vitamin D excess)

🚑 Hypercalcaemia Emergency Algorithm (Ward Management)

Step	Action	Clinical Notes
1️⃣ Confirm Hypercalcaemia	Check albumin-adjusted calcium Repeat sample to confirm Assess severity	Mild: 2.6–3.0 mmol/L Moderate: 3.0–3.5 mmol/L Severe: >3.5 mmol/L
2️⃣ Assess Patient	ABCDE assessment Hydration status Neurological symptoms ECG monitoring	Look for: Confusion Dehydration Polyuria Short QT on ECG
3️⃣ Initial Treatment	💧 IV 0.9% saline Typical rate: 2–4 L in first 24 h Adjust for elderly or heart failure	Hydration restores renal calcium excretion and is the first-line treatment.
4️⃣ Identify Cause	PTH U&Es Phosphate Vitamin D Myeloma screen CXR / imaging if malignancy suspected	PTH interpretation: ↑ or normal → Primary hyperparathyroidism ↓ → Malignancy / vitamin D excess / granulomatous disease
5️⃣ If Calcium Remains High	💉 IV Zoledronic acid 4 mg Alternative: Pamidronate 60–90 mg IV	Onset: 24–48 h Peak effect: 4–7 days
6️⃣ Severe / Refractory	Calcitonin (short-term effect) Denosumab if bisphosphonate-resistant Dialysis if renal failure or life-threatening hypercalcaemia	Usually managed with endocrine or oncology input.
7️⃣ Definitive Treatment	Treat the underlying cause.	Parathyroidectomy for primary hyperparathyroidism Oncology management for malignancy Steroids for sarcoidosis or lymphoma

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🎓 Exam Tips – Hypercalcaemia

👉 Primary hyperparathyroidism is the most common cause of hypercalcaemia in the community.
👉 Malignancy is the most common cause of severe hypercalcaemia in hospital.
👉 Always check PTH first when investigating hypercalcaemia.
👉 The ECG change classically associated with hypercalcaemia is short QT interval.
👉 IV saline hydration is the first-line treatment before giving bisphosphonates.
👉 Hypercalcaemia symptoms are remembered by the phrase: "Bones, Stones, Groans, and Psychiatric Overtones".

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Hypercalcaemia ✅

🚑 Hypercalcaemia Emergency Management – Ward Algorithm

1️⃣ Immediate Clinical Assessment