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

Author credits / conflict declaration No financial conflicts of interest

Content Medication class Indications Actions Warnings Summary

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

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

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

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

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

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

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

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