Key points
- We recommend to consult your poison center with the use of this antidote.
- In the case of poisoning by co-ingestion of digitalis glycosides, the use of calcium is not recommended until treatment with digoxin Fab fragments is administered.
- One ml of a 10% solution (1 g/10 ml; 100 mg/ml) of calcium chloride contains 27 mg (0.673 mmol) of elemental calcium.
- Treatment Algorithms for Cardiovascular Toxicity
+ Synonyms and other terms
- Calcium chloride
- CaCl2
+ Indications
- Indicated for the treatment of hypotension, bradycardia or conduction disorders due to calcium channel blocker poisoning.
- Indicated for the treatment of hypocalcemia due to hydrogen fluoride or to soluble salts of fluoride and bifluoride (ex: ammonium bifluoride).
+ Dosage
+ Pediatric Dose
- Bolus (IV direct) via central line only: 10 to 20 mg/kg (0.1 to 0.2 ml/kg) (max of 1000 mg) of calcium chloride 10%. If necessary, repeat every 10 min. up to a maximum of 4 doses.
or
- IV continuous infusion via central line only: 10-20 mg/kg/h (0.1-0.2 ml/kg/h) of calcium chloride 10%. Titrate infusion rate based on serum ionized calcium concentration and efficacy (vital signs)
+ Adult Dose
- Bolus (IV direct) via central line only: 1 to 2 g (10 to 20 ml) of calcium chloride 10%. If necessary, repeat every 10 minutes up to a maximum of 4 doses.
or
- IV continuous infusion via central line only: 0.02-0.04 g/kg/h (0.2-0.4ml/kg/h) of calcium chloride 10%.Titrate infusion rate based on serum ionized calcium concentration and efficacy (vital signs)
+ Renal Impairment
- No data suggests that the dose should be modified for short-term use.
- However, serum calcium levels will need to be closely monitored (e.g., every 2 hours).
+ Hepatic Impairment
No data suggests that the dose should be modified for short-term use.
+ Hemodialysis Patient
No data suggests that the dose should be modified for short-term use.
+ Pregnancy
- The safety of high doses has not been demonstrated.
- However, do not hesitate to use the calcium during pregnancy if the anticipated toxic effects pose a significant risk of morbidity or mortality.
- No data suggests that the dose should be modified for short-term use.
+ Obese or Overweight Patient
No data suggests that the dose should be modified for short-term use.
+ Adverse effects
- Hypotension, bradycardia and possible arrhythmia if rapid injection (poisoning by calcium-channel blocker)
- Burning sensation at injection site if administered as a bolus.
- Risk of deterioration of myocardial function in the event of significant hypercalcemia.
- Subcutaneous calcinosis and tissue necrosis in the event of extravasation.
- Arterial spasms during calcium infusion, nausea, vomiting, abdominal cramp by parenteral route, hypercalcemia.
+ Monitoring
- Vital signs
- Serum calcium levels; target serum ionized calcium of 1.5 mmol/L
- EKG
+ End of treatment
- Stable hemodynamics or significant hypercalcemia (more than 1.75 mmol/L of ionized calcium).
+ Special Notes on Administration
Intravenous Route (IV)
Direct IV:
- Administer the solution for injection at a concentration of 100 mg/ml (10%) by direct IV over 10 min.
- Small doses can be diluted in NS to facilitate administration.
- Administer by central line only.
- Administer using a volumetric pump.
- Rinse tubing after each injection using 2.5 to 30 ml of NS to reduce the risk of thrombophlebitis.
IV infusion:
- Preparation: Withdraw the desired volume of calcium chloride 10% from the vial and transfer to either an empty IV solute bag (eg Viaflex) or an empty syringe (See section: Stability for additional information).
- Eg, : 112ml of calcium chloride 10% is required for an infusion at the maximal rate of 0.4ml/kg/h for a duration of 4 hours for a patient weighing 70kg.
- Administration: Administer by central line only using a volumetric pump.
Intraosseous Route (IO)
- Possible alternative to IV route.
Subcutaneous Route (SC)
- DO NOT ADMINISTER SC. Will result in severe tissue necrosis and desquamation.
Intramuscular Route (IM)
- DO NOT ADMINISTER IM. Will result in severe tissue necrosis and desquamation.
Compatibility
Partial list only. Consult the pharmacist on duty at your healthcare facility.
- Compatible solutions: NS, D5W, D5W+NS, D5W+½NS, D5W+¼NS, D10W, D50W, LR, Plasma-Lyte A.
- Y-site compatibility: amiodarone, dobutamine, epinephrine, esmolol, insulin, morphine, nitroprussiate, norepinephrine.
- Y-site incompatibility: sodium bicarbonate, propofol.
Stability
Calcium chloride 10% and calcium gluconate 10% solutions are physically stable at least 48 hours at room temperature (25 ºC, 60% relative humidity) in polypropylene syringe and in empty intravenous solute bag who contains PVC and DEHP.
+ Available products
- Calcium chloride for injection, USP, 100 mg/ml, inj. Sol. syringe, 10 ml (Abboject or Lifeshield), Pfizer Canada ULC, DIN 00294748,
- Calcium chloride for injection, USP, 100 mg/ml, in. sol., vials of 10 ml or 50 ml, Omega Laboratories Ltd, DIN 00821780,
+ Amount required to treat a person weighting 70kg during 24 hours
- At least 20 g.
+ References
Sim, Michael T., and Frazier T. Stevenson. 2008. “A Fatal Case of Iatrogenic Hypercalcemia after Calcium Channel Blocker Overdose.” Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology 4 (1):25–29.
St-Onge, M., P-A Dubé, S. Gosselin, C. Guimont, J. Godwin, P. M. Archambault, J-M Chauny, et al. 2014. “Treatment for Calcium Channel Blocker Poisoning: A Systematic Review.” Clinical Toxicology 52 (9):926–44.
St-Onge, Maude, Kurt Anseeuw, Frank Lee Cantrell, Ian C. Gilchrist, Philippe Hantson, Benoit Bailey, Valéry Lavergne, et al. 2017. “Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults.” Critical Care Medicine 45 (3):e306–15.
Worthley L.I.G, Letters to the Editor:Treating Adverse Effects of verapamil, JAMA Sept 7 1984, Vol 254(9) p1129
Hamelin A, Thompson-Desormeaux R, Elliott A et al. Y-site simulation compatibility study of 10% calcium salts with various injectable solutions during toxicological resuscitation, Eur J Hosp Pharm 2023;0:1-5. doi:10.1136/ejhpharm-2023-003689.
