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Calcium: limited indications, some danger
Insights
Calcium chloride is not proven to improve survival for cardiac arrest patients with asystole or electromechanical dissociation (EMD). While it may improve resuscitation rates in EMD, long-term survival remains poor, questioning its routine use.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Pharmacology
Background:
- Calcium chloride has been historically used for cardiac resuscitation since the 1920s.
- Concerns exist regarding side effects and dangerously elevated serum calcium levels with recommended dosages.
- Previous studies have yielded conflicting results on its efficacy.
Purpose of the Study:
- To evaluate the effectiveness of calcium chloride in improving survival rates for patients with asystole and electromechanical dissociation (EMD).
- To assess the safety and efficacy of calcium chloride administration during cardiopulmonary resuscitation (CPR).
Main Methods:
- A prospective, randomized, double-blind study comparing calcium chloride versus saline placebo in a paramedic system.
- Analysis of resuscitation rates and long-term survival in patients experiencing asystole and EMD.
- Review of existing retrospective clinical studies and case reports.
Main Results:
- No statistically significant difference in resuscitation or long-term survival was observed for asystole patients treated with calcium chloride versus placebo.
- Patients with EMD showed improved resuscitation rates with calcium chloride, but only one survived to hospital discharge.
- Studies indicate that recommended dosages can lead to dangerously high serum calcium levels.
Conclusions:
- Routine use of calcium chloride in asystole and EMD is not supported by current evidence due to lack of demonstrated benefit.
- Further large-scale multicenter trials are needed to definitively prove or disprove its efficacy in these cardiac arrest rhythms.
- Calcium administration remains indicated for patients with confirmed or suspected hypocalcemia or hyperkalemia.
Abstract:
Calcium chloride has been advocated since the 1920s for the resuscitation of asystole, electromechanical dissociation (EMD), and ventricular fibrillation. Reports of side effects and complications have been numerous. Studies of calcium assays following American Heart Association recommended dosages have shown dangerously elevated serum levels. Large retrospective clinical studies in Milwaukee and Tampa have found no evidence of improved survival with calcium chloride in asystole and EMD. A prospective randomized double-blind study comparing calcium chloride and saline controls in the Milwaukee Paramedic system for asystole and EMD using standard AHA protocols showed no statistically significant difference in resuscitation rates or long-term survival between the calcium and no-calcium groups for the rhythm of asystole. Although patients with EMD had statistically improved resuscitation rates when calcium chloride was given, only one of the patients survived to hospital discharge. Because of the low rates of resuscitation and long-term survival in patients presenting in asystole and EMD, proving that calcium chloride does not enhance survival would require large multicenter trials. However, since no controlled study has ever documented significant benefit, its routine use in asystole and EMD cannot be supported. Calcium has long been used in medical treatment of hypocalcemic and hyperkalemic states and should be administered in moribund patients who have the proper clinical history and clinical signs of hypocalcemia.