Hypocalcemia

Casey Grover, MD

Disclosures

July 19, 2012

A 17 year-old female with a history of total thyroidectomy was sent to the emergency department (ED) for an abnormal lab study. The patient reported a previous history of electrolyte problems with which she felt "twitchy," yet reported no symptoms during this ED evaluation. A blood pressure cuff was placed on the patient's right arm and inflated to a pressure above the patient's systolic blood pressure. After approximately 2 minutes, the patient's right hand developed a contracted position (Figure 1, left panel). Within seconds of release of the cuff, the patient's hand returned to a normal position (Figure 2, right panel).

Figure 1 (left panel) and Figure 2 (right panel).

Diagnosis:
Hypocalcemia. A serum calcium obtained in the ED was 6.9, with an ionized calcium of 0.85. The patient was given two grams of intravenous calcium gluconate and was discharged home to follow up with her endocrinologist the following morning.

The development of carpal spasm in patients with hypocalcemia after placement of a blood pressure cuff on the arm that is inflated above systolic pressure is known as Trousseau's sign. The spasm causes the hand to develop a characteristic position, as in this patient, within 3 minutes of cuff inflation. Hypocalcemia is most commonly from low vitamin D levels, hypoparathyroidism, small intestinal disease with malabsorption and adverse medication effects. It is also a well-recognized complication after thyroid and parathyroid surgery, as in this patient. Common symptoms include muscular spasm, tingling and numbness. Severely affected patients may develop seizures and cardiac dysrhythmias.

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