1. Calcium Chloride Christopher J. Fullagar, MD, EMT-P, FACEP
Daniel J. Hind, Pharm. D.
Daniela Tierson, Pharm. D.

2. Author credits / conflict declaration
No financial conflicts of interest

3. Content
Medication class
Indications
Actions
Warnings
Summary

4. Medication Class
Calcium is a mineral; an electrolyte
Calcium chloride is a calcium salt
In the collaborative EMS formulary, calcium is available as a 10% solution of calcium chloride

5. Indications
The ONLY standing order indications for calcium chloride administration are cardiac arrest or rhythm changes during rapid sequence intubation (RSI) (paramedics only)
All other indications require a medical control order:
Other causes of hyperkalemia
Calcium channel blocker overdose

6. Indications
Consider hyperkalemia in at-risk patients with:
Prolonged QTc > 500 milliseconds
Widened QRS > 150 milliseconds
Patients at-risk for hyperkalemia:
Dialysis patients
Digitalis overdose
Massive crush injury
Cardiac arrest or cardiac rhythm changes after succinylcholine administration

7. Actions
The use of calcium chloride in hyperkalemia does not decrease the serum potassium level; instead it helps to “stabilize the myocardial cell membrane” against undesirable depolarization from the high levels of potassium (see notes for more)
Calcium is often reserved for patients that have cardiac effects of hyperkalemia as manifested by the aforementioned QTc and QRS abnormalities
Elevated potassium levels can induce the depolarization of the resting membrane potential of the cardiac myocytes. This leads to an inactivation of the sodium channels and decreased membrane excitability. This can lead to conduction abnormalities, such as bundle branch blocks and fatal arrhythmias.
*Notes attached

8. Variably effective, but may be considered in severe cases
Actions
In calcium channel blocker (CCB) overdose, calcium chloride may help to overcome the effect of the CCB
Variably effective, but may be considered in severe cases
Usually requires additional interventions in the hospital
Not much evidence favoring the use of calcium chloride in beta blocker overdose
Severe cases of calcium channel blocker overdose may be treated in the hospital with additional isotonic crystalloid and calcium salts, glucagon, high dose insulin and glucose, and other interventions. (The amount of glucagon we typically carry in the ambulance is not sufficient to overcome severe calcium channel or beta blockade).
*Notes attached

9. Warnings
Calcium chloride will form a precipitate if it combines with sodium bicarbonate
The precipitate is calcium carbonate, the same component that is in chalk
If you must give calcium chloride and sodium bicarbonate via the same intravenous line, flush with at least 50 cc of normal saline between the bolus of calcium chloride and sodium bicarbonate
Chalk in the vascular system is considered a bad thing.
*Notes attached

10. Tissue necrosis secondary to extravasation injuries
Warnings
Calcium chloride that extravasates into the tissue can cause tissue necrosis
Calcium chloride should only be administered via a large, proximal, easily flowing IV
Administer slowly and stop if there is any concern of extravasation
Immediately report all instances of suspected extravasation of calcium chloride to hospital staff
Extravasation of medications, such as chemotherapeutic agents and calcium salts, can lead to tissue necrosis. Calcium chloride should not be administered in the hand. Some medications are available in the hospital, such as hyaluronidase, to treat calcium salt extravasation. It should be administered as soon as possible, ideally within one hour of extravasation.
Tissue necrosis secondary to extravasation injuries
*Notes attached

11. Summary
Calcium chloride can be given by paramedics on standing order only for cardiac arrest or rhythm changes after administration of succinylcholine during RSI
Calcium chloride is otherwise reserved for use by online medical control order for hyperkalemia with resultant ECG abnormalities and severe calcium channel blocker overdose
Only administer calcium chloride slowly via a large, proximal, easily flowing line to decrease the risk of tissue necrosis from extravasation of the drug into the soft tissue
If giving calcium chloride and sodium bicarbonate via the same IV line, flush with at least 50 cc of normal saline between boluses