Calcium for Cardiac Arrest. Let’s get to the brass tacks!

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The Pre-brief

Calcium administration during cardiac arrest, irrespective of the initial rhythm, has no proven benefit and is not recommended by the International Liaison Committee on Resuscitation (ILCOR) or American Heart Association (AHA). Yet, we still see in many cases calcium being administered in cardiac arrest.  So what does the data show?

In 1974 the first ACLS guidelines were published by the AHA. Within these guidelines, many recommendations for cardiac arrest management were not well supported by evidence. One of these recommendations was the administration of calcium during cardiac arrest. After many revisions, AHA and the European Resuscitation Council finally published recommendations removing calcium from their recommendations stating a lack of data to support its use and suggesting potential harm.

Two great systematic reviews of calcium administration for cardiac arrest by Kette et al. and Landry et al. reviewed all the available data.  They found no evidence to support the use of calcium in cardiac arrest. Their conclusions state there is very limited data utilizing randomized, blinded controlled trials, large sample sizes, and the use of predetermined algorithms for interventions to help identify possible benefits or harms of calcium administration during cardiac arrest. 

Kette et al. looked at two sets of literature. One was on the correlation of acidosis causing hypocalcemia leading to adverse cardiac function and whether correcting the electrolyte imbalance would restore function. The literature showed no evidence to support improved survival or return of spontaneous circulation. The second set of studies looked at whether calcium administration during cardiac arrest would benefit cardiac function irrespective of rhythm. Again, there was no data to support calcium use in cardiac arrest. Even as a last resort, there was no effect, possibly because mortality and time in cardiac arrest are directly correlated.  

Commentary by Jeff Pepin:

I do not administer calcium for undifferentiated cardiac arrest unless I believe the cause of the arrest is from hyperkalemia, CCB overdose, or hypocalcemia. In this case, I administer calcium chloride through an IO or central venous access. In hyperkalemia and CCB overdose, there are concomitant medications that are beneficial not covered in this post but should be strongly considered.

The Debrief

  • The indiscriminate administration of Calcium during cardiac arrest is not supported by current evidence.
  • Clinicians should focus on minimizing the interruption of high-quality chest compressions and early defibrillation when indicated.
  • The administration of medications not supported by evidence during cardiac arrest will add to the cognitive load of the resuscitationists and distract them from performing important procedures and giving life-saving medications.
  • Calcium may be indicated in the setting of a confirmed or suspected overdose of a calcium channel blocker, or hyperkalemia.

References

  1. Landry A, Foran M, Koyfman A. Does calcium administration during cardiopulmonary resuscitation improve survival for patients in cardiac arrest? Ann Emerg Med. 2014;64(2):187-189. doi:10.1016/j.annemergmed.2013.07.510
  2. Kette F, Ghuman J, Parr M. Calcium administration during cardiac arrest: A systematic review. Eur J Emerg Med. 2013;20(2):72-78. doi:10.1097/MEJ.0b013e328358e336

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