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Toxicity, Fluoride: Treatment & Medication
Updated: Dec 2, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Place patients with a known significant ingestion of fluoride on a cardiac monitor and initiate an IV line. Administer calcium IV to patients who present with cardiac dysrhythmias.
Emergency Department Care
- Provide cardiac monitoring.
- Hypocalcemia may be detected.
- Perform gastric aspiration and lavage. Small-bore nasogastric tube aspiration, followed by lavage, is recommended because of the potential severity of this ingestion and the ineffective absorption of fluoride by activated charcoal. Lavage with milk or a solution containing calcium or magnesium hydroxide (eg, milk of magnesia) is theoretically attractive but has not been proven beneficial. Some recommend lavaging with 1-5% calcium chloride solution to bind fluoride in the stomach.
- Gastric aspiration and lavage are most effective when instituted within 1 hour of ingestion.
- Administer milk, calcium carbonate, and aluminum- and magnesium-based antacids (eg, hydroxides) to bind fluoride.
- Activated charcoal is not helpful. Fluoride does not bind to charcoal. Activated charcoal still is recommended for those with intentional ingestions when a polysubstance overdose is possible.
- Correct calcium deficiencies with IV calcium chloride.
Consultations
- Consult a toxicologist or poison control center for acute management recommendations.
- Psychiatric consultation is necessary after medical clearance.
Medication
Goals of therapy are to reduce toxicity and prevent complications.
Electrolytes
Calcium chloride is administered to correct hypocalcemia that may result from fluoride poisoning. Calcium chloride provides 3 times more calcium than calcium gluconate on an equal-volume basis and is preferred (despite greater tissue toxicity if extravasation occurs).
Calcium chloride
Manages underlying hypocalcemic effects caused by fluoride poisoning.
Adult
Initial dose: 1-2 g (1-2 ampules) IV slow push of 10% calcium chloride solution (10 mL each); repeat doses to obtain desired serum calcium level; for severe poisoning, may need to give multiple grams for the first several hours
Pediatric
20-25 mg/kg IV push of calcium chloride; repeat as necessary; may need massive doses with severe poisoning
Coadministration with digoxin may cause arrhythmias; with thiazides, may induce hypercalcemia; may antagonize effects of calcium channel blockers, atenolol, and sodium polystyrene sulfonate
Ventricular fibrillation not associated with hyperkalemia; digitalis toxicity, hypercalcemia, renal insufficiency, cardiac disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer slowly (not to exceed 0.5-1 mL/min) to avoid extravasation; hypercalcemia may occur in renal failure
Calcium gluconate (Kalcinate)
Moderates nerve and muscle performance and facilitates normal cardiac function. For systemic hypocalcemia, agent can be given IV initially, and then calcium levels can be maintained with high calcium diet. Some patients will require oral calcium supplementation. For topical pain, agent can be applied as a water-soluble gel mixture.
Adult
May apply 2.5-5% calcium gluconate to affected area; repeat as often as required for pain control; if not available commercially, prepare as a simple 3:1 (for 2.5%) or 1:1 (for 5%) dilution of a 10% IV solution in a water-soluble surgical gel or similar sterile base
Pediatric
Apply as in adults
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; antagonizes effects of verapamil; large intakes of dietary fiber may decrease calcium absorption and levels; interactions likely not significant for calcium administered via topical route
Renal calculi, hypercalcemia, hypophosphatemia, renal or cardiac disease, and digitalis toxicity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in digitalized patients, respiratory failure, acidosis, or severe hyperphosphatemia; monitor serum calcium when calcium gluconate is administered parenterally
More on Toxicity, Fluoride |
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| Differential Diagnoses & Workup: Toxicity, Fluoride |
 Treatment & Medication: Toxicity, Fluoride |
| Follow-up: Toxicity, Fluoride |
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References
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Augenstein WL, Spoerke DG, Kulig KW, et al. Fluoride ingestion in children: a review of 87 cases. Pediatrics. Nov 1991;88(5):907-12. [Medline].
Eichler HG, Lenz K, Fuhrmann M, Hruby K. Accidental ingestion of NaF tablets by children--report of a poison control center and one case. Int J Clin Pharmacol Ther Toxicol. Jul 1982;20(7):334-8. [Medline].
Gessner BD, Beller M, Middaugh JP, Whitford GM. Acute fluoride poisoning from a public water system. N Engl J Med. Jan 13 1994;330(2):95-9. [Medline].
Kao WF, Deng JF, Chiang SC. A simple, safe, and efficient way to treat severe fluoride poisoning--oral calcium or magnesium. J Toxicol Clin Toxicol. 2004;42(1):33-40. [Medline].
Klasaer AE, Scalzo AJ, Blume C, et al. Marked hypocalcemia and ventricular fibrillation in two pediatric patients exposed to a fluoride-containing wheel cleaner. Ann Emerg Med. Dec 1996;28(6):713-8. [Medline].
McIvor ME. Acute fluoride toxicity. Pathophysiology and management. Drug Saf. Mar-Apr 1990;5(2):79-85. [Medline].
Schneir A, Clark RF, Kene M, Betten D. Systemic fluoride poisoning and death from inhalational exposure to sulfuryl fluoride. Clin Toxicol (Phila). Jun 16 2008;1-5. [Medline].
Shulman JD, Wells LM. Acute fluoride toxicity from ingesting home-use dental products in children, birth to 6 years of age. J Public Health Dent. Summer 1997;57(3):150-8. [Medline].
Vance M. Fluoride poisoning. In: The Clinical Process of Emergency Medicine. Vol 1. 1991:507-9.
Further Reading
Keywords
fluoride poisoning, fluoride toxicity, fluoride ingestion, toothpaste, sodium monofluorophosphate, dietary supplement, sodium fluoride, glass-etching agent, chrome-cleaning agent, ammonium bifluoride, insecticide, rodenticide
