Calcium Administration in Cardiac Arrest
Date First Published:
March 10, 2026
Last Updated:
March 10, 2026
Report by:
Simon Carley, Consultant (Manchester NHS Foundation Trust)
Three-Part Question:
In adult patients in cardiac arrest, compared to placebo or standard care improve In adult patients in cardiac arrest ROSC, survival to hospital admission, survival to hospital discharge, or neurological outcomes?
Clinical Scenario:
You are working in a busy emergency department when a 65-year-old patient presents in cardiac arrest. During resuscitation, a colleague suggests administering calcium to improve the chances of return of spontaneous circulation (ROSC) and survival. You recall that calcium administration is recommended in specific cases (e.g., hyperkalemia, hypocalcemia, calcium channel blocker overdose) but are uncertain about its routine use in cardiac arrest. You decide to review the evidence.
Search Strategy:
Ovid MEDLINE(R) ALL 1946 to February 18, 2026, EMBASE (via Ovid) to March 2025, Cochrane Library to March 2025
Search Details:
(exp Cardiac Arrest/ OR (cardiac arrest OR OHCA OR IHCA OR "out-of-hospital cardiac arrest" OR "in-hospital cardiac arrest").tw,kf.) AND (exp Calcium/ OR (calcium OR "calcium chloride" OR "calcium gluconate").tw,kf.) AND (exp Resuscitation Outcomes/ OR (ROSC OR "return of spontaneous circulation" OR survival OR "neurological outcome" OR "hospital discharge").tw,kf.) limit to humans and english language.
Outcome:
Ovid MEDLINE(R) ALL 1946 to February 18, 2026: 29 papers; EMBASE (via Ovid): 18 papers; Cochrane Library: 6 papers. A total of 53 papers were identified, of which 6 directly addressed the three-part question and were included in the BET.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Efficacy of emergency department calcium administration in cardiac arrest: A 9-year retrospective evaluation. Dillon DG, Wang RC, Shetty P, Douchee J, Rodriguez RM, Montoy JCC. 2023 USA | ED patients treated for cardiac arrest | Retrospective cohort study (Level 3) | Survival to hospital admission | Calcium administration associated with decreased survival to hospital admission: 31.2% (calcium) vs. 41.8% (no calcium). | Retrospective design, potential confounders not fully controlled |
| The effectiveness of calcium chloride in refractory electromechanical dissociation. Stueven HA, Thompson B, Aprahamian C, Tonsfeldt DJ, Kastenson EH. 1985 USA | Patients with refractory electromechanical dissociation | Prospective observational study (Level 3) | ROSC | Calcium administration showed no significant benefit in improving ROSC or survival rates: 2/13 (15%) (calcium) vs. 3/14 (21%) (no calcium). | Small sample size, observational design |
| Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest: a randomized clinical trial. Vallentin MF, Granfeldt A, Meilandt C, et al. 2021 Denmark | OHCA patients receiving IV/IO calcium vs. saline | Double-blind RCT (Level 1) | ROSC, survival to discharge | No benefit of IV/IO calcium administration; significantly lower ROSC in the calcium group: 19% (calcium) vs. 27% (placebo); survival to discharge: 3.6% (calcium) vs. 5.2% (placebo). | Trial stopped early, limiting statistical powe |
| Long-term outcomes of calcium administration during out-of-hospital cardiac arrest: a follow-up study. Vallentin MF, Granfeldt A, Meilandt C, et al. 2022 Denmark | OHCA patients receiving IV/IO calcium vs. saline (long-term outcomes) | Follow-up study (Level 1) | Survival at 1 year, neurological outcomes | Lower survival and unfavorable neurological outcomes at 1 year in the calcium group: Survival at 1 year: 1.9% (calcium) vs. 3.5% (placebo); poor neurological outcome: 98.1% (calcium) vs. 96.5% (placebo). | Follow-up study, potential loss to follow-up |
| Calcium during cardiac arrest: A systematic review. Hsu CH, Couper K, Nix T, Drennan I, Reynolds J, Kleinman M, Berg KM. 2023 ILCOR review | Systematic review and meta-analysis of calcium in cardiac arrest | Systematic review (Level 1) | ROSC, survival to discharge | No evidence supporting routine calcium administration; potential harm indicated: Pooled ROSC: 21% (calcium) vs. 26% (control); survival to discharge: 4% (calcium) vs. 6% (control | Limited number of high-quality RCTs included |
Author Commentary:
The available evidence evaluating calcium administration during cardiac arrest is relatively limited and heterogeneous, consisting of one contemporary randomized controlled trial, observational cohort data, historical prospective studies, and a recent systematic review. The strongest evidence comes from the randomized controlled trial by Vallentin et al., which demonstrated lower rates of ROSC and no improvement in survival outcomes with calcium compared to placebo. Observational data from Dillon et al. support these findings, suggesting reduced survival to hospital admission among patients receiving empiric calcium in the emergency department, although residual confounding cannot be excluded. Earlier prospective work by Stueven et al. failed to demonstrate benefit in refractory arrest rhythms, but these studies were small and conducted in a different era of resuscitation practice. The systematic review by Hsu et al. synthesizes the contemporary literature and similarly concludes that routine calcium administration is not supported by current evidence. Overall, while calcium remains indicated in specific reversible causes of cardiac arrest such as hyperkalaemia, hypocalcaemia, or calcium channel blocker toxicity, the cumulative evidence does not support routine empiric administration during adult cardiac arrest.
Bottom Line:
Routine empiric calcium administration during adult cardiac arrest does not improve ROSC, survival, or neurological outcomes and should be reserved for specific indications such as hyperkalaemia, hypocalcaemia, or calcium channel blocker toxicity.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Dillon DG, Wang RC, Shetty P, Douchee J, Rodriguez RM, Montoy JCC.. Efficacy of emergency department calcium administration in cardiac arrest: A 9-year retrospective evaluation.
- Stueven HA, Thompson B, Aprahamian C, Tonsfeldt DJ, Kastenson EH.. The effectiveness of calcium chloride in refractory electromechanical dissociation.
- Vallentin MF, Granfeldt A, Meilandt C, et al.. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest: a randomized clinical trial.
- Vallentin MF, Granfeldt A, Meilandt C, et al.. Long-term outcomes of calcium administration during out-of-hospital cardiac arrest: a follow-up study.
- Hsu CH, Couper K, Nix T, Drennan I, Reynolds J, Kleinman M, Berg KM.. Calcium during cardiac arrest: A systematic review.