On The Streets #15: Hydrofluoric Acid Case Review

Contributors:

• Kalen Abbott, MD - EM Physician and Medical Director for AirLife Denver

• Brendan Reiss - Flight Nurse AirLife Denver

• Matt Spoon - Flight Paramedic AirLife Denver

• Jordan Ourada - EMS Coordinator at Swedish Medical Center and Paramedic

Summary:

In this episode, hosted by Jordan Ourada, Brendan Reiss and Matt Spoon present a first-hand experience case of hydrofluoric acid exposure in a pediatric patient. Commentary and educational pearls are provided by EM Physician, Kalen Abbott.

The case: 

• The patient was a male infant who had spilled a large amount of heavy-duty acid aluminum wheel cleaner on himself while playing in his parent's garage. Unclear if he had ingested any fluid. The cleaning fluid contained a large percentage of hydrofluoric acid.

• He was brought by EMS to his local hospital, who quickly decided to transport the infant by helicopter to a large Denver hospital.

• Initial labs were unremarkable and the EKG was normal. Heart rate was in the 140s. Blood pressure was 110/73. Respirations were around 30 and non-labored. Chest and abdominal x-rays were unremarkable.

• The patient had received a water-based decontamination and 1 gram of calcium gluconate IV.

Complications:

• Immediately before leaving a nurse informed Brendan and Matt that the serum calcium was 6.8 mg/dl (normal range: 8.5 to 10.2).

• During the flight, the patient went into cardiac arrest.

• The patient achieved ROSC after CPR was administered in the helicopter.

• Once on the ground, an I/O line was started and calcium chloride, sodium bicarb, and normal saline were administered.

• Within the first 2 hours that patient received the equivalent of 310 mg/kg of calcium (the pediatric dose is 20 mg/kg)

Care resolution:

• The patient ended up having a several-week stay in the pediatric ICU. There were some complications such as pulmonary hemorrhage. Calcium gluconate was continued via nebulization for several days. Ultimately, the child was weaned off the ventilator and spontaneous respirations resumed. They were able to wean the child off vasopressors and sedation over the course of several days. A gastric lavage with calcium gluconate was completed as well during the inpatient stay. The child was able to leave the hospital, neurologically intact after about 14 days. 

Pearls:

• Lower concentrations of acids can be more dangerous because they don't immediately burn but rather can be absorbed systemically through the skin.

• Calcium is the antidote to hydrofluoric acid exposure.

• Calcium chloride has 3 times the elemental calcium as calcium gluconate.

• The maximum infusion rate of calcium chloride through a peripheral line is 1 gram every 10 minutes, calcium gluconate can be infused at 1 gram every 5 minutes.

• When intubating a patient with acid exposure, avoid succinylcholine because of the risk of hyperkalemia.

References

1. Caravati EM. Acute hydrofluoric acid exposure. Am J Emerg Med. 1988 Mar;6(2):143-50. doi: 10.1016/0735-6757(88)90053-8. PMID: 3281684.

2. Pepe J, Colangelo L, Biamonte F, Sonato C, Danese VC, Cecchetti V, Occhiuto M, Piazzolla V, De Martino V, Ferrone F, Minisola S, Cipriani C. Diagnosis and management of hypocalcemia. Endocrine. 2020 Sep;69(3):485-495. doi: 10.1007/s12020-020-02324-2. Epub 2020 May 4. PMID: 32367335.

3. Strayer RJ. Succinylcholine, rocuronium, and hyperkalemia. Am J Emerg Med. 2016 Aug;34(8):1705-6. doi: 10.1016/j.ajem.2016.05.039. Epub 2016 May 19. PMID: 27241569.

4. Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Dec 14;326(22):2268-2276. doi: 10.1001/jama.2021.20929. PMID: 34847226; PMCID: PMC8634154.

Summarized by Jeffrey Olson MS2 | Edited by Jeffrey Olson, Meg Joyce, & Jorge Chalit, OMSII