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Key points

  • We recommend to consult your poison centre with the use of this antidote.
  • In the case of poisoning by co-ingestion of digitalis glycosides, the use of calcium is not recommended until treatment with digoxin Fab fragments is administered.
  • One ml of a 10% solution (1 g/10 ml 100 mg/ml) of calcium gluconate contains 9.3 mg (0.23 mmol) of elemental calcium.
  • Treatment Algorithms for Cardiovascular Toxicity 
  • For exposure to hydrofluoric acid (HF) or ammonium bifluoride, be sure to decontaminate skin properly (e.g., water, hexafluorine (commercial name) solution) and debride and clean nails. Cutaneous signs are not indicative of burn severity. Rely on the intensity of the pain instead.
  • If HF or ammonium bifluoride burn is on more than 1% of the body surface with a concentrated solution (greater or equal to 50% for HF), watch for signs of systemic involvement (hypocalcemia, hypomagnesemia and symptomatic hyperkalemia with cardiac dysrhythmias).
  • If HF or ammonium bifluoride burn is ocular, irrigation with a crystalloid solution is the first choice. LR has a more suitable pH than NS, but both can be used.

+ Synonyms and other terms

  • Calcium gluconate
  • HF antidote gel, Calgonate (topical gel)

+ Indications

  • Treatment of hypotension, bradycardia or conduction disorders due to poisoning with a calcium-channel blocker.
  • Ingestion or cutaneous exposure to hydrofluoric acid (HF) or to soluble salts of fluoride and bifluoride (ex: ammonium bifluoride).

+ Dosage

+ Pediatric Dose

Poisoning by a calcium-channel blocker:

  • Bolus (IV direct): 30 - 60 mg/kg (0.3-0.6 ml/kg/h) (maximum of 3000 mg) of calcium gluconate 10% by direct IV. If necessary, repeat every 10 minutes for a maximum of 4 doses.

or

  • IV continuous infusion: 30-60 mg/kg/h (0.3-0.6 ml/kg/h) of calcium gluconate 10%. Titrate infusion rate based on serum ionized calcium concentration and efficacy (vital signs).

Dermal Exposure to HF or ammonium bifluoride:

  • Topical application is preferred after proper washing of the skin (make sure to clean the nails). If treatment fails, use a regional block or intra-arterial infusion if an extremity is involved, or a subcutaneous injection if other areas are affected. If multiple sites on the same extremity are affected, intra-arterial infusion can be used from the outset.
    • Topical
      • Fingers: Place calcium gluconate 2.5% gel in a surgical glove to cover the affected finger(s). Massage the area to increase penetration. Change the gel every 4 h until relief is obtained for more than 4 h without gel.
      • Other areas: Apply gel. Cover with non-absorbent bandage. Massage the area to increase penetration. Change gel every 4 h until relief is obtained for more than 4 h without gel.
      • Recipe for preparing a 2.5% gel is provided in the section; Special Notes on Administration.
    • Subcutaneous Injection
      • 0.5 ml/cm2 of solution for injection concentrated at 10% with a 25- or 27-gauge needle. Do not inject in fingers, ears or tip of the nose to avoid compromising circulation.
    • Regional Block: Bier Block
      • IV Route: Insert catheter on affected limb proximal to burn and a pneumatic tourniquet above. Put 1000 mg (10 ml) of calcium gluconate 10% in 40 ml of NS. Inflate the tourniquet. Administer 0.25 ml/kg (max 25 ml) of the preparation. Slowly release the tourniquet after 20 min. Make sure blood flow is maintained in the extremity.
    • Intra-arterial Infusion
      • Prepare 1 g (10 ml) of calcium gluconate 10% in 40 ml of D5W and administer over 4 h, 0.1 ml/kg (max 10 ml) in an arterial catheter proximal to burns. Repeat infusion until relief for more than 4 h.

+ Adult Dose

Poisoning by a calcium-channel blocker

  • Bolus (IV direct): 3 to 6 g (30-60 ml) of calcium gluconate 10%. If necessary, repeat every 10 minutes for a maximum of 4 doses.

or

  • IV continuous infusion: 0.06-0.12 g/kg/h (0.6-1.2 ml/kg/h) of calcium gluconate 10%. Titrate infusion rate based on serum ionized calcium concentration and efficacy (vital signs).

Dermal Exposure to HF or ammonium bifluoride

  • Topical application is preferred after proper washing of the skin (make sure to clean the nails). If treatment fails, use a regional block or intra-arterial infusion if an extremity is involved, or a subcutaneous injection if other areas are affected. If multiple sites on the same extremity are affected, intra-arterial infusion can be used from the outset
    • Topical
      • Fingers: Place calcium gluconate 2.5% gel in a surgical glove to cover the affected finger(s). Massage the area to increase penetration. Change gel every 4 h until relief is obtained for more than 4 h without gel.
      • Other areas: Apply gel. Cover with non-absorbent bandage. Massage the area to increase penetration. Change gel every 4 h until relief is obtained for more than 4 h without gel.
      • Recipe for preparing a 2.5% gel is provided in the section; Special Notes on Administration.
    • Subcutaneous Injection
      • 0.5 ml/cm2 of solution for injection concentrated at 10% with a 25- or 27-gauge needle. Do not inject in fingers, ears or tip of the nose to avoid compromising circulation.
    • Regional Block: Bier Block
      • IV Route: Insert catheter on affected limb proximal to burn and a pneumatic tourniquet above. Put 1000 mg (10 ml) of calcium gluconate 10% in 40 ml of NS. Inflate the tourniquet. Administer 25 - 50 ml of the preparation. Slowly release the tourniquet after 20 min. Make sure blood flow is maintained in the extremity.
    • Intra-arterial Infusion
      • Use 10 ml of calcium gluconate 10% in 40 ml of D5W and administer by an arterial catheter proximal to burns. Administer over 4 h. Repeat infusion until relief is obtained for more than 4 h.

+ Renal Impairment

  • No data suggests that the dose should be modified for short-term use.
  • However, serum calcium levels must be closely monitored (e.g., every 2 hours).

+ Hepatic Impairment

No data suggests that the dose should be modified for short-term use.

+ Hemodialysis Patient

  • No data suggests that the dose should be modified for short-term use.

+ Pregnancy

  • The safety of large doses has not been demonstrated.
  • However, do not hesitate to use the calcium during pregnancy if the anticipated toxic effects pose a significant risk of morbidity or mortality.
  • No data suggests that the dose should be modified for short-term use.

+ Obese or Overweight Patient

No data suggests that the dose should be modified for short-term use.

+ Adverse effects

  • Hypotension, bradycardia and possible arrhythmias, if rapid intravenous injection (poisoning by calcium-channel blocker).
  • Burning sensation at injection site if administered as a bolus.
  • Risk of deterioration of myocardial function in the event of significant hypercalcemia.
  • Subcutaneous calcinosis and tissue necrosis in the event of extravasation
  • Arterial spasms during calcium infusion, nausea, vomiting, abdominal cramps by parenteral route, hypercalcemia.

+ Monitoring

  • If risk of systemic toxicity of HF or ammonium bifluoride (See Key Points).
  • EKG
  • Heart monitor if abnormal EKG or electrolytic disorders.
  • Monitor ionized calcium, magnesium and potassium regularly throughout the treatment.
    • Target serum ionized calcium of 1.5 mmol/L

+ End of treatment

  • Calcium-channel blocker: Patient hemodynamically stable or hypercalcaemia (ex: more than 1.75 mmol/L of ionized calcium).
  • Dermal Exposure to HF or ammonium bifluoride: Complete relief of symptoms more than 4 h after discontinuation of calcium.

+ Special Notes on Administration

Intravenous Route (IV)

  • Direct IV:
    • Administer the solution for injection at a concentration of 100 mg/ml (10%) by direct IV over 10 min.
    • Small doses can be diluted in NS to facilitate administration.
    • Administer using a volumetric pump.
    • Rinse tubing after each injection using 2.5 to 30 ml of NS to reduce the risk of thrombophlebitis.
  • IV infusion:
    • ​Preparation:  Withdraw the desired volume of calcium gluconate 10% from the vial and transfer to either an empty IV solute bag (eg. Viaflex) or an empty syringe (see Section Stability for more information).
      • Eg,: 168ml of calcium gluconate 10% is required for an infusion at the minimal rate of 0.6 ml/kg/h for a duration of 4 hours for a patient weighing 70 kg.
    • Administration: Administer using a volumetric pump.

Intraosseous Route (IO)

  • No data available.

Subcutaneous Route (SC)

  • Can be administered SC for exposure to the hydrofluoric acid (HF) or ammonium bifluoride.
  • Use solution for injection concentrated at 100 mg/ml with a 25- or 27-gauge needle.

Intramuscular Route (IM)

  • Not recommended (calcifications)

Topical Route

  • Suggested preparation:
  • Put 10 ml (1000 mg) of 10% calcium gluconate for injection into a 10-ml syringe.
  • Put 30 ml of K-Y (other lubricants may not be compatible) into a sterile container (e.g., urine sample container).
  • Add the content of the syringe to the gel and stir to mix well (you can use syringe needle to stir).
  • Final approximate concentration: 2.5%

Intra-arterial Route

  • Suggested preparation:
    • 10 ml (1000 mg) in 40 ml of D5W.
    • Final volume = 50 ml Final concentration = 20 mg/ml.
    • Infusion by intra-arterial route over 4 h.
    • Administer using a volumetric pump.

Compatibility

Partial list only. Consult the pharmacist on duty at your health care facility.

  • Compatible solutions: NS, D5W, D10W, D5W+NS, D5W+½NS, D5w+¼NS, D10W, D50W, LR, Plasma-Lyte A.
  • Y-site compatibility: insulin, epinephrine, nitroprusside (in D5W), norepinephrine, potassium (chloride; in D5W or NS).
  • Y-site incompatibility: prochlorperazine

Stability

  • Physically stable for 24 h in NS or D5W.
  • Calcium chloride 10% and calcium gluconate 10% solutions are physically stable at least 48 hours at room temperature (25 ºC, 60% relative humidity) in polypropylene syringe and in empty intravenous solute bag who contains PVC and DEHP.

+ Available products

Injectable Formula:

  • Calcium gluconate for injection USP, 100 mg/ml (10%), inj.. Sol., single-use vial of 10 and 50 ml, bulk vial of 100 ml for pharmacy (no preservatives), Fresenius Kabi Canada , DIN 02141019, 

Topical Gel

  • Calgonate 2.5%, Topical Gel, 25 g per tube, Calgonate Corp. , DIN = None (Stability of 2 years)
  • Calcium gluconate 2.5%, Topical Gel, 30 g in a glass jar, Galenova , Product Code 1494 - 030, DIN = None (Stability of 2 years)
  • Calcium gluconate 2.5%, Topical Gel, 50 g in a metal tube, Pharmacy Boissinot , DIN = None (Stability of 30 days)

+ Amount required to treat a person weighting 70kg during 24 hours

  • At least 20 g of solution for IV use.
  • For dermal exposure to HF or ammonium bifluoride, at least 50 g of calcium gluconate topical gel 2.5% or the necessary supplies to prepare an extemporaneous mixture is required.

+ References

Dünser, Martin W., Markus Ohlbauer, Josef Rieder, Isabella Zimmermann, Helmut Ruatti, Anton H. Schwabegger, Florian Bodrogi, et al. 2004. “Critical Care Management of Major Hydrofluoric Acid Burns: A Case Report, Review of the Literature, and Recommendations for Therapy.” Burns: Journal of the International Society for Burn Injuries 30 (4):391–98.



St-Onge, M., P-A Dubé, S. Gosselin, C. Guimont, J. Godwin, P. M. Archambault, J-M Chauny, et al. 2014. “Treatment for Calcium Channel Blocker Poisoning: A Systematic Review.” Clinical Toxicology 52 (9):926–44.



St-Onge, Maude, Kurt Anseeuw, Frank Lee Cantrell, Ian C. Gilchrist, Philippe Hantson, Benoit Bailey, Valéry Lavergne, et al. 2017. “Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults.” Critical Care Medicine 45 (3):e306–15.

Hamelin A, Thompson-Desormeaux R, Elliott A et al. Y-site simulation compatibility study of 10% calcium salts with various injectable solutions during toxicological resuscitation, Eur J Hosp Pharm 2023;0:1-5. doi:10.1136/ejhpharm-2023-003689.


Last updated : 2024-01-30