What are the indications for calcium chloride?

Indications for Calcium Chloride

Calcium chloride is FDA-approved for treating acute hypocalcemia requiring rapid plasma calcium elevation, and is recommended by the American Heart Association for stabilizing the myocardial membrane in severe hyperkalemia with ECG changes and during cardiac arrest associated with hypermagnesemia. 1, 2

FDA-Approved Primary Indication

• Acute hypocalcemia requiring prompt increase in plasma calcium levels 1

Evidence-Based Emergency Indications

Severe Hyperkalemia with Cardiotoxicity

• Administer 10% calcium chloride 5-10 mL (500-1000 mg) IV over 2-5 minutes when hyperkalemia causes ECG changes (peaked T waves, widened QRS, absent P waves, sine-wave pattern) 2
• Calcium acts as a cardioprotective agent by stabilizing the myocardial cell membrane but does not lower potassium levels 2
• Must be combined with therapies that shift potassium intracellularly (insulin/glucose, sodium bicarbonate, albuterol) and promote excretion (diuretics, dialysis) 2
• Recent 2024 animal data showed calcium chloride did not improve return of spontaneous circulation in hyperkalemia-induced cardiac arrest, though human guidelines still support its use 3

Hypermagnesemia with Cardiac Arrest or Severe Cardiotoxicity

• Administer 10% calcium chloride 5-10 mL IV over 2-5 minutes during cardiac arrest associated with hypermagnesemia (Class IIb, Level of Evidence C) 2
• May be considered for severe hypermagnesemia causing bradycardia, cardiac arrhythmias, or cardiorespiratory compromise 2

Calcium Channel Blocker Toxicity

• Administer 10% calcium chloride 0.6 mL/kg over 5-10 minutes for hemodynamic instability from calcium channel blocker poisoning 2
• May follow with continuous infusion at 0.3 mEq/kg per hour 2

Important Clinical Caveats

Administration Safety

• Administer through a central venous catheter whenever possible—peripheral IV extravasation causes severe skin and soft tissue necrosis requiring debridement and skin grafting 2, 4
• Continuous ECG monitoring is mandatory during administration, especially in patients on cardiac glycosides 2, 5
• Stop infusion immediately if symptomatic bradycardia occurs or heart rate drops by 10 beats per minute 5, 6
• Never mix calcium chloride with sodium bicarbonate in the same IV line due to precipitation risk 5

Dosing Considerations

• Pediatric dose: 5 mg/kg rapid bolus (maximum 300 mg), may repeat up to total daily dose of 15 mg/kg 2
• The FDA label does not specify exact dosing for hyperkalemia or hypermagnesemia, noting these uses lack adequate well-controlled randomized trials 1

Contraindications and Limitations

• Routine use in asystole and electromechanical dissociation (PEA) is NOT supported—multiple studies from the 1980s showed no survival benefit, and this practice has been abandoned 7, 8
• Do not use for asymptomatic hypocalcemia 5
• In tumor lysis syndrome with hyperphosphatemia, calcium administration increases risk of calcium phosphate precipitation—obtain renal consultation first 5

Calcium Chloride vs. Calcium Gluconate

• Calcium chloride provides approximately 3 times more elemental calcium per volume than calcium gluconate 5
• Calcium gluconate is preferred for peripheral IV administration due to less tissue irritation if extravasation occurs 6
• For emergency hyperkalemia treatment, either formulation is acceptable: calcium chloride 5-10 mL (10%) OR calcium gluconate 15-30 mL (10%) 2