Do not use IV calcium as initial therapy in patients with chronic kidney disease who are asymptomatic or who have stable hypocalcemia with only mild symptoms (eg, paresthesias) ( Ref). Correct concurrent hypomagnesemia if present ( Ref). Should also be used in patients whose symptoms did not improve with or who can no longer take oral calcium. Note: For use in patients with severe symptoms of hypocalcemia (eg, tetany, seizures, carpopedal spasm), ECG abnormalities (eg, QTc prolongation, arrhythmia), or an acute decrease in albumin-corrected serum calcium levels to <7 to 7.5 mg/dL (<1.75 to 1.87 mmol/L) when serious complications may occur if untreated (eg, following neck surgery). Hydrofluoric acid inhalational exposure, treatment: Inhalation (off-label route): 2.5% nebulization solution: Mix 1.5 mL of 10% calcium gluconate solution with 4.5 mL NS to make a 2.5% solution and administer via nebulization repeat doses may be given after medical evaluation ( Ref). IV (Bier block technique) (off-label route): Add 1.5 g (15 mL of a 10% solution) to 35 mL of NS and infuse over 2 minutes using a Bier block technique ( Ref). A poison information center or clinical toxicologist should be consulted prior to implementation. Extreme care should be taken to avoid the extravasation. This intervention should be used only by those accustomed to this technique. Pain usually resolves by the end of the infusion repeat if pain recurs. Infuse over 4 hours into the artery that provides the vascular supply to the affected area ( Ref). Intra-arterial (off-label route): Add 1 g (10 mL of a 10% solution) to 50 mL of D5W. Local anesthesia may be required to perform procedure pain resolution is the therapeutic endpoint and if a local anesthetic is utilized, it may be difficult to determine the success of therapy ( Note: Never use calcium chloride for SUBQ injection as it may result in severe dermal necrosis). Infiltration should be carried 0.5 cm away from the margin of the injured tissue into the surrounding uninjured areas. SUBQ (off-label route): 5% to 10% solution: 0.5 mL/cm 2 of burned tissue ( Ref). Note: If commercially available or extemporaneously compounded gel is unavailable, then topical application of wet compresses made with the 10% calcium gluconate IV solution may be used immediately following decontamination ( Ref). The use of gel-filled condom for penile exposure has been reported ( Ref). Note: Surgical gloves filled with gel are useful for hand burns ( Ref). Topical: 2.5% gel: After washing the affected area, apply liberally and allow the application to stay on the affected area for ≥30 minutes or for ≥15 minutes past the point of pain resolution, whichever is longer cover and redress every 4 hours as needed. Monitor serum calcium level if serum calcium level is not within normal range, then give an additional 1 g, followed by 4 g over 1 hour, as needed, to maintain serum calcium levels ( Ref). IV: 2 g immediately or as soon as possible after exposure (before serum calcium level is known). Additional treatment measures may be required (eg, magnesium) ( Ref) consultation with a clinical toxicologist or poison control center is highly recommended. Systemic toxicity, prevention and treatment: Note: Profound and precipitous hypocalcemia may occur after exposure to higher hydrofluoric acid concentrations to even a small surface area ( Ref). Hydrofluoric acid exposure (off-label use):
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