Rosen & Barkin's 5-Minute Emergency Medicine Consult (361 page)

• Calcitonin: 4 IU/kg IM/SC q12h
  
• Etidronate: 7.5 mg/kg over 4 hr daily for 3–7 days IV
  
• Furosemide: 10–40 mg q6–8h (peds: 1–2 mg/kg) IV
  
• Pamidronate: Single 2–24 hr infusion of 60–90 mg IV (peds: Consult pediatrician)
  

• Gallium nitrate: Continuous infusion of 200 mg/m
  ²
  /d for 5 days IV
  
• Hydrocortisone: 200–400 mg/d IV for 3–5 days (peds: Consult pediatrician)
  
• Plicamycin: 25 μg/kg/d over 4–6 hr IV for 3–8 doses
  

• In infants, loop diuretics are rarely necessary and possibly harmful as they may decrease glomerular filtration rate and worsen hypercalcemia
  
• Bisphosphonates have not been extensively studied in pediatrics but do appear to be safe
  

FOLLOW-UP

• Corrected total calcium level >13 mg/dL
  
• Signs or symptoms attributed to hypercalcemia, especially EKG changes
  
• Monitored bed or ICU for corrected level >14 or serious signs and symptoms
  

Corrected calcium level <13 mg/dL and no signs or symptoms of hypercalcemia

• Rapid follow-up arranged to determine cause and long-term therapy
  
• Consultation with endocrinologist should be considered
  

• Fluid hydration
  
• Watch for mental status changes
  

• Make decisions based on symptoms or corrected Ca levels
  
• All patients with serum Ca >14 mg/dL require treatment regardless of symptoms
  
• Pay careful attention to EKG changes
  
• Careful monitoring is required for patients receiving IV volume repletion:
  
  • They often require a large volume of fluid but care must be taken to avoid volume overload
    

• Ariyan CE, Sosa JA. Assessment and management of patients with abnormal calcium.
  Crit Care Med
  . 2004;32(suppl 4):S146–S154.
  
• Inzucchi SE. Management of hypercalcemia. Diagnostic workup, therapeutic options for hyperparathyroidism and other common causes.
  Postgrad Med
  . 2004;115:27–36.
  
• Lietman SA, Germain-Lee EL, Levine MA. Hypercalcemia in children and adolescents.
  Curr Opin Pediatr
  . 2010;22(4):508–515.
  
• Marx JA, Hockberger RS, Walls RM, eds.
  Rosen’s Emergency Medicine
  . Philadelphia, PA: Elsevier; 2009.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Hyperparathyroidism
  
• Hypocalcemia
  
• Hypoparathyroidism
  

CODES

• 275.42 Hypercalcemia
  
• 275.49 Other disorders of calcium metabolism
  
• 588.89 Other specified disorders resulting from impaired renal function
  

BASICS

• Hyperemesis gravidarum is the most severe form along the continuum of nausea and vomiting of pregnancy
  
• Also known as pernicious vomiting of pregnancy
  
• Characterized by unexplained intractable vomiting and dehydration
  
• Occurs in 0.3–2% of pregnancies
  
• Diagnosis of exclusion
  

• Exact cause unknown
  
• Possible causes include the following:
  
  • Elevated gestational hormone levels of human chorionic gonadotropin (hCG) and/or estradiol
    
  • Thyrotoxicosis
    
  • Upper GI motility dysfunction
    
  • Hepatic abnormalities
    
  • Autonomic nervous system dysfunction
    
  • Psychological factors
    
  • Helicobacter pylori
    infection
    
  • Genetic predisposition
    

DIAGNOSIS

• Nausea and vomiting during pregnancy affects between 50% and 90%
  
• Onset of symptoms by the 4th–10th wk of pregnancy with resolution by the 20th:
  
  • Symptoms after the 20th wk should raise one’s suspicion of another process
    
• Peak onset is at 8–12 wks
  
• Hyperemesis gravidarum is a clinical diagnosis defined by the following:
  
  • Persistent and severe nausea and vomiting
    
  • Dehydration
    
  • Weight loss of >5% of total body weight
    
  • Lab findings: Increased urine specific gravity, ketonuria, electrolyte disturbances, ketonemia
    

• Onset of vomiting
  
• Gestational history:
  
  • Similar symptoms in prior pregnancies
    
• Last menstrual period
  
• Oral intake
  
• Urine output
  
• Bloody or bilious vomiting
  
• Abdominal pain
  
• Vaginal bleeding
  
• Risk factors include the following:
  
  • History of motion sickness
    
  • Younger age
    
  • Migraine headaches
    
  • Symptoms earlier in the day
    
  • Low prepregnancy body mass index
    
  • More common in nulliparous women
    
  • 15% recurrence rate if manifested in previous pregnancy
    

• Observe for signs of dehydration
  
• Abdominal tenderness
  

• History and physical exam with special attention to state of hydration and abdominal exam for other diagnoses associated with vomiting (appendicitis, cholecystitis, etc.)
  
• Obtain an uncontaminated urinalysis
  
• If patient has unremitting vomiting for >24 hr, obtain a CBC, electrolytes, renal function, liver enzymes, bilirubin, and lipase
  

• Urinalysis:
  
  • Increased specific gravity and ketonuria
    
  • Presence of glucose mandates checking serum glucose to rule out diabetes
    
  • Presence of bilirubin mandates a search to rule out hepatobiliary cause for the vomiting
    
• CBC:
  
  • May have an elevated hematocrit owing to dehydration
    
  • WBC is usually normal
    
• Electrolytes:
  
  • Elevated BUN indicating volume depletion; elevated creatinine if renal failure present
    
  • Hyponatremia, hypokalemia, hypochloremia, and metabolic alkalosis from loss of HCl in emesis
    
• Liver function tests:
  
  • Mild increases in bilirubin may occur, but should be <4 mg/dL.
    
  • AST and ALT may also be mildly elevated, but not >100 IU/L
    
• Amylase/lipase:
  
  • In 1 study, amylase was elevated in 24% of patients with hyperemesis gravidarum; however, the amylase was salivary in origin; use lipase rather than amylase to evaluate for pancreatitis
    
• TSH
  
• Serum hCG levels are not indicated if known intrauterine pregnancy
  

• US when 1st trimester US has not been performed to evaluate for:
  
  • Molar pregnancy
    
  • Multiple gestations
    

• Pyelonephritis; most commonly missed
  
• Gastroenteritis; gastroparesis; intestinal obstruction; Mallory–Weiss tear
  
• Hepatobiliary disease; hepatitis, cholecystitis, fatty liver of pregnancy, achalasia
  
• Pancreatitis
  
• Appendicitis
  
• Diabetic ketoacidosis
  
• Hyperthyroidism; hyperparathyroidism
  
• Uremia; persistent nausea and vomiting are seen with severe renal dysfunction.
  
• Pseudotumor cerebri
  

TREATMENT