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eMedicine Journal
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Emergency Medicine
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Toxicology
Toxicity, Fluoride Synonyms, Key Words, and Related Terms: fluoride poisoning, toothpaste, sodium monofluorophosphate, dietary supplement, sodium fluoride, glass-etching agent, chrome-cleaning agent, ammonium bifluoride, insecticide, rodenticide, fluoride toxicity, fluoride ingestion |
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 | AUTHOR INFORMATION | Section 1 of 11    |
Authored by Geofrey Nochimson, MD, Consulting Staff, Department of Emergency Medicine, Sentara Careplex Hospital
Geofrey Nochimson, MD, is a member of the following medical societies: American College of Emergency Physicians
Edited by David C Lee, MD, Research Director, Assistant Professor, Department of Emergency Medicine, North Shore University Hospital and New York University Medical School; John T VanDeVoort, PharmD, Clinical Assistant Professor, College of Pharmacy, University of Minnesota; Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Asim Tarabar, MD, Assistant Clinical Professor of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
| Author's Email: | Geofrey Nochimson, MD |  |
|---|---|---|
| Editor's Email: | David C Lee, MD |
eMedicine Journal, January 8 2007, VOLUME 8,
Number 1
| INTRODUCTION | Section 2 of 11  |
Background: Fluoride toxicity is characterized by a variety of signs and symptoms. Poisoning most commonly occurs following ingestion (accidental or intentional) of fluoride-containing products. Symptom onset usually occurs within minutes of exposure.
Fluoride is found in many common household products, including toothpaste (eg, sodium monofluorophosphate), dietary supplements (eg, sodium fluoride), glass-etching or chrome-cleaning agents (eg, ammonium bifluoride), and insecticides and rodenticides (eg, sodium fluoride). Historically, most cases of fluoride toxicity have followed accidental ingestion of insecticides or rodenticides.
Pathophysiology: Fluoride has several mechanisms of toxicity. Ingested fluoride initially acts locally on the intestinal mucosa. It can form hydrofluoric acid in the stomach, which leads to GI irritation or corrosive effects. Following ingestion, the GI tract is the earliest and most commonly affected organ system.
Once absorbed, fluoride binds calcium ions and may lead to hypocalcemia. Fluoride has direct cytotoxic effects and interferes with a number of enzyme systems; it disrupts oxidative phosphorylation, glycolysis, coagulation, and neurotransmission (by binding calcium). Fluoride inhibits Na+/K+ -ATPase, which may lead to hyperkalemia by extracellular release of potassium. Fluoride inhibits acetylcholinesterase, which may be partly responsible for hypersalivation, vomiting, and diarrhea (cholinergic signs). Seizures may result from both hypomagnesemia and hypocalcemia. Severe fluoride toxicity will result in multiorgan failure. Central vasomotor depression as well as direct cardiotoxicity also may occur. Death usually results from respiratory paralysis, dysrhythmia, or cardiac failure.
Frequency:
Only 440 cases were actually treated in the emergency department.
Mortality/Morbidity: One death from ingestion of fluoride toothpaste was reported to the American Association of Poison Control Centers in 2002.
No deaths were reported in 2004.
Age: Children younger than 6 years account for the vast majority of the cases. In 2004, this age group had a total 21,890 exposures, while adults 19 years and older had only 1213 exposures.
| CLINICAL | Section 3 of 11 |
History:
Physical:
Causes:
| DIFFERENTIALS | Section 4 of 11 |
Plant Poisoning, Herbs
Plant Poisoning, Licorice
Toxicity, Acetaminophen
Toxicity, Ammonia
Toxicity, Antihistamine
Toxicity, Arsenic
Toxicity, Chlorine Gas
Toxicity, Heavy Metals
Toxicity, Mushroom - Amatoxin
Toxicity, Mushroom - Disulfiramlike Toxins
Toxicity, Mushroom - Gyromitra Toxin
Toxicity, Mushroom - Hallucinogens
Toxicity, Mushroom - Orellanine
Toxicity, Scombroid
| WORKUP | Section 5 of 11 |
Lab Studies:
| TREATMENT | Section 6 of 11 |
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:
Consultations:
| MEDICATION | Section 7 of 11 |
Goals of therapy are to reduce toxicity and prevent complications.
Drug Category: 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).
| Drug Name | Calcium chloride -- Manages underlying hypocalcemic effects caused by fluoride poisoning. |
|---|---|
| Adult Dose | 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 h |
| Pediatric Dose | 20-25 mg/kg IV push of calcium chloride; repeat as necessary; may need massive doses with severe poisoning |
| Contraindications | Ventricular fibrillation not associated with hyperkalemia; digitalis toxicity, hypercalcemia, renal insufficiency, cardiac disease |
| Interactions | Coadministration with digoxin may cause arrhythmias; with thiazides, may induce hypercalcemia; may antagonize effects of calcium channel blockers, atenolol, and sodium polystyrene sulfonate |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Administer slowly (not to exceed 0.5-1 mL/min) to avoid extravasation; hypercalcemia may occur in renal failure |
| Drug Name | 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 Dose | 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 Dose | Apply as in adults |
| Contraindications | Renal calculi, hypercalcemia, hypophosphatemia, renal or cardiac disease, and digitalis toxicity |
| Interactions | 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 |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Caution in digitalized patients, respiratory failure, acidosis, or severe hyperphosphatemia; monitor serum calcium when calcium gluconate is administered parenterally |
| FOLLOW-UP | Section 8 of 11 |
Further Inpatient Care:
Deterrence/Prevention:
Prognosis:
Patient Education:
| MISCELLANEOUS | Section 9 of 11 |
Medical/Legal Pitfalls:
| TEST QUESTIONS | Section 10 of 11 |
CME Question 1: Which electrolyte abnormality is observed with fluoride poisoning?
A: Hypernatremia
B: Hypokalemia
C: Hypocalcemia
D: Hypermagnesemia
E: Hyperglycemia
The correct answer is C: Hypocalcemia, hyperkalemia, and hypomagnesemia commonly are observed in fluoride poisoning. Hypoglycemia may occur occasionally.
CME Question 2: Which of the following is not useful in the management of fluoride poisoning?
A: Milk
B: Activated charcoal
C: Antacids
D: Ipecac
E: Gastric lavage
The correct answer is B: Charcoal has proven unhelpful, while milk, antacids, ipecac, and gastric lavage may be helpful in certain situations.
Pearl Question 1 (T/F): Signs and symptoms of fluoride ingestion occur after 2 hours.
The correct answer is False: Signs and symptoms occur within minutes of exposure.
Pearl Question 2 (T/F): Hypernatremia is the most common electrolyte abnormality observed in fluoride poisoning.
The correct answer is False: Hypocalcemia, hypomagnesemia, and hyperkalemia are the most common electrolyte abnormalities observed in fluoride poisoning.
Pearl Question 3 (T/F): The estimated toxic dose of fluoride is 5-10 mg/kg.
The correct answer is True: Toxic dose is approximately 5-10 mg/kg.
Pearl Question 4 (T/F): An EEG is the most important ancillary test to obtain in all fluoride poisoning cases.
The correct answer is False: Obtain an ECG to help determine fluoride poisoning.
| BIBLIOGRAPHY | Section 11 of 11 |
| NOTE: |
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| Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER |
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