Ca mg po4_lecture
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CALCIUM, MAGNESIUM, PHOSPHORUSSANGIL LEE, MD, MSRESIDENT LECTURE 12/1/2016
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DISCLOSURE
• None
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OBJECTIVES
• 1. Understand the mechanism of Ca/Mg/PO4 associated pathology• 2. List differentials and propose diagnostic workup• 3. Propose therapeutic intervention
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HERE ARE SOME QUESTIONS
• Q1. You should use Calcium Gluconate/Calcium Chloride for emergent calcium supplementation.
• Q2. Name three medications you can use for hypercalcemia.• Q3. Name electolyte treatment for Torsades De Pointes. And also,
indicate the dosage.• Q4. Indicate the level of Magnesium when DTR diminishes• Q5. What are the signs and symptoms of low phosphorus?
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CALCIUM
• Regulation by GUT, BONE, Kidneys • Parathyroid hormone, Calcitonin, Vitamine D
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CALCIUM
• Normal range 8.5 to 10.5 mg/dl • Ionized fraction if physiologically active (>2.0meq/l)
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CALCIUM
• Hypocalcemia (Serum Ca <8.5mg/dl, i-Ca<2.0meq/L)• Causes: Systemic illness, Vitamin D and Drugs
Shock, Sepsis, Renal failure, Pancreatitis and low albumin
Vitamin D: Hypoparathyroidism, Hyperphosphatemia,
Malignancy
Drugs: Phosphates, Dilantin,
Phenobarbital, Cisplatin, Heparin,
Loop diuretics, Glucocorticoids,
Magnesium, Sulfate
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SIGNS AND SYMPTOMS OF HYPOCALCEMIA
Neurological: Circumoral and Digital paresthesias, Tetany, Chvostek sign, Trousseau sign, Confusion, Hallucination, Seizures
MSK: Spasms, Weakness, Osteodystrophy, Rickets, Osteomalacia
CV: Heart failure, Prolongeal QT
Video for Chvostek and Trousseau signs
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TREATMENT FOR HYPOCALCEMIA
• Symptomatic or severe• 10% Calcium Gluconate, 10-30ml• 10% Calcium Chloride IV, 10ml
Chloride=CODE
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HYPERCALCEMIA
• Total Ca >10.5 mg/dl• i Ca>2.7 meq/L
DrugsEndocrinopa
thyMalignancy
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HYPERCALCEMIA- SIGNS AND SYMPTOMSSTONES, BONES, MOANS, AND GROANS
Am Fam Physician. 2003 May 1;67(9):1959-1966.
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HYPERCALCEMIA -RX
• IVF to restore euvolemia- hours• Lasix 40mg-100mg IV Q2-4hr- hours• Decrease bone/GI absorption (Calcitonin, Corticosteroid, Bisphosphate)-
days
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MAGNESIUM
• Intracellular Cation• Range 1.5meq/L-2.5meq/L• Tends to correlate with K and Ca
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HYPOMAGNESEMIA
Redistribution of lytes (DKA Rx)
Decreased intake(ETOH, malnutrition)
Extrarenal loss (diarrhea, burn, sepsis)Renal loss (Drugs, SIADH, Hyperthyroidism, Hyperparathyroidism
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MAGNESIUM- HYPOMGNESEMIA
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MAGNESIUM- HYPOMAGNESEMIA
Treatment???
1. Remove offending agent2. Add K3. Cardioversion4. Isopretelenol5. Atropin and Pacing6. Magnesium – 1-2GM IV
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HYPERMAGNESEMIA- MG >2.5MEQ/L
Renal failure
Increased Mg load
Increased renal absorption
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HYPERMAGNESEMIA- SIGNS AND SYMPTOMS
Nausea >2.0meq/L
Somnolence >3.0meq/L
Decreased/absent DTRs >4.0meq/L
ECG abnormality >5.0meq/L
Apnea >8meq/L
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HYPERMAGNESEMIA- RX
• Dilution w IVF• Lasix 40-80mg IV• Calcium (antagonist for neuromuscular and cardiovascular effect)• HD
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PHOSPHORUS
• Intracellular anion• 2.5 to 4.5 mg/dl
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PHOSPHORUS-LOW PHOS
• Sx at PO4 < 1.0mg/dl• Weakness• Paresthesia• Decreased DTR• Confusion• Anorexia• Rx: 2.5mg/kg IV over 6hrs
Decreased oral intake
Excessive loss
Shift from ECF-ICF
Endocrine (Parathyroidism, DKA,
AKA)
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PHOSPHORUS-HIGH PHOS
• Sx at PO4 > 2.5mg/dl• Sx of renal failure• Sx of low Mg, low Ca• Rx: Rx underlying cause• Rx: Dilute with IVF• Rx Acetazolamide• Rx Aluminium Carbonate/Hydroxide
Decreased excretion
Shift from ICF-ECF
Increased intake
Endocrine (Hypoparathyroidis
m)
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SUMMARY
• Q1. You should use Calcium Gluconate/Calcium Chloride for emergent calcium supplementation.
• Q2. Name three medications you can use for hypercalcemia. • Q3. Name electolyte treatment for Torsades De Pointes. • Q4. Indicate the level of Magnesium when DTR diminishes • Q5. What are the signs and symptoms of low phosphorus?
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SUMMARY
• Q1. You should use Calcium Gluconate/Calcium Chloride for emergent calcium supplementation. A: Calcium Chloride
• Q2. Name three medications you can use for hypercalcemia. A: Lasix, Calcitonin, Dexamethasone
• Q3. Name electrolyte treatment for Torsades De Pointes. A: MgSO4, 1-2GM IV
• Q4. Indicate the level of Magnesium when DTR diminishes A: 4.0meq/L• Q5. What are the signs and symptoms of low phosphorus? A: Weakness
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THANK YOU!
• Questions?