Indications

• Systemic hypocalcemia due to hydrofluoric acid exposure or ethylene glycol toxicity.
• Dermal and inhalational hydrofluoric acid exposures.
• Hypotension and bradycardia due to calcium channel blocker or beta blocker overdose. (calcium chloride preferred; refer to monograph)

Dosage

CALCIUM CHANNEL BLOCKER/BETA BLOCKER OVERDOSE AND HYPOCALCEMIA

• 30 mg/kg/dose calcium gluconate (0.3 mL/kg/dose of a 10% solution) IV over 10 minutes.
• Repeat every 10 - 20 minutes as required; after four doses, monitor serum calcium levels and reassess. If effective for reversing hypotension and bradycardia, continue with this regimen. If ineffective, further treatment should focus on other, more effective antidotes (see Insulin, Glucagon and Lipid Emulsion monographs).

HYDROFLUORIC ACID EXPOSURES BY ROUTE OF EXPOSURE:

Dermal Exposure
Prior to any calcium, perform irrigation of affected area with copious amounts of water.

A. Topical Treatment:
- Massage 2.5% calcium gluconate jelly into affected area until pain has subsided. If pain persists after 15 to 30 minutes, consider other routes of administration (see below).

- Calcium gluconate 2.5% jelly is a commercially available product or can be prepared by combining 20 mL of 10% calcium gluconate solution with 56 g of K-Y Jelly or Muko lubricating jelly. (NOTE: Only KY Jelly or Muko brand lubricating jelly are compatible with Calcium Gluconate in the preparation of Calcium Gluconate Gel.)

- Secure treated area with occlusive cover (e.g. opsite or latex glove if fingers/hand affected).

B. IF TOPICAL TREATMENT FAILS, USE ONE OF THE FOLLOWING METHODS

1. Subcutaneous:
This is NOT recommended for fingers or toes unless physician is experienced with the technique. Injections may be painful. Regional nerve block is recommended.

- Inject 10% calcium gluconate subcutaneously through a 30gauge needle; maximum dose 0.5 mL/cm² skin
- Repeat as needed to control pain.

2. Regional IV Infusion
This is an option for burns of forearm, hand and fingers as an adjunct to topical therapy or if topical therapy fails

- Infuse 1 g (50 mL) of calcium gluconate 2% (20 mg/mL) in affected limb using a Bier block technique.  For a final concentration of 20 mg/mL: add 10 mL of 10% calcium gluconate injection to 40 mL sodium chloride 0.9%. Total volume 50 mL. 
- Maintain ischemia for 20 - 25 minutes; release cuff sequentially over 3 - 5 minutes.

3. Intra-arterial Infusion (No data in pediatrics)
This is for severe burns or failure of regional IV infusion. Experienced physician to place intra-arterial catheter in appropriate vascular supply close to site of the dermal exposure (eg. Radial, ulnar, or brachial artery)

- Infuse 1 g (50 mL) of calcium gluconate 2% (20 mg/mL) over 4 hours.  For a final concentration of 20 mg/mL: add 10 mL of 10% calcium gluconate injection to 40 mL sodium chloride 0.9%. Total volume 50 mL. 
- May repeat every 4 hours until pain subsides

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Inhalation Exposure

Nebulized Treatment:

- Add 150 mg (1.5 mL of a 10% calcium gluconate injection) to 6 mL of sterile water in nebulizer
- Adjust oxygen flow to provide sufficient fog (6 - 8 L/minute)