findings in patients with neuromuscular instability include Trousseau sign and Chvostek sign A positive Trousseau sign is causing a carpopedal spasm by inflation of a sphygmomanometer above systolic blood pressure for minutes A positive Chvostek sign is contraction of the ipsilateral facial muscle induced by tapping of the facial nerve in front of the ear Of note, Chvostek sign may be present in up to 10% of normal subjects In addition to neuromuscular findings, acute hypocalcemia may result in significant cardiovascular disturbance, including hypotension, congestive heart failure, prolonged QT interval, and dysrhythmias Papilledema may also be present and resolves with correction of hypocalcemia Management Numerous forms of calcium salts are available, and therefore, attention to the salt form is critical when dosing to determine the elemental calcium dose Calcium may be provided by either oral supplementation or IV solution The appropriate choice is guided by pertinent clinical findings In general, IV calcium is indicated if the patient has prolonged QT, significant symptoms (tetany, seizures, carpopedal spasm), or acute decrease in serum corrected calcium to less than or equal to 7.5 mg/dL regardless of symptoms Oral supplementation is more appropriate when symptoms are absent or mild and corrected calcium is greater than or equal to 7.5 mg/dL In patients with asymptomatic chronic hypocalcemia associated with CKD, oral calcium supplementation is preferred with concomitant replacement of 1,25-dihydroxyvitamin D If hypocalcemia is associated with metabolic acidosis, correction of the acidosis will reduce the ionized calcium level Therefore, if metabolic acidosis is not causing clinical compromise, priority should be given to increasing the serum calcium If hypocalcemia is associated with severe hyperphosphatemia, the provision of calcium may result in the precipitation of calcium and phosphate in the tissues, a disorder known as calciphylaxis In patients with associated hypomagnesemia, magnesium supplements should be provided, as persistent hypomagnesemia will hinder the correction of hypocalcemia Prompt treatment of symptomatic or severe acute hypocalcemia should be initiated intravenously with either calcium chloride or calcium gluconate Central access is usually necessary for calcium chloride infusions, although peripheral infusions may be permissible in emergent situations Central access is also preferred for calcium gluconate, though