Intraosseous Calcium vs Saline for ROSC in OHCA

Dr. Lauren Friend and Dr. Eric Krueger

The Case

You receive a radio call form EMS that they are 5 minutes away with a 60-ish year-old John Doe that they have been doing CPR on for approximately 10 minutes. He was found by a member of the public who does not know the patient or have any medical history. No obvious signs of trauma.

Indications for Calcium During Cardiac Arrest? Hyperkalemia

The Paper

Design: Double-blind placebo-controlled randomized clinical trial

Time: January 2020 - April 2021

Location: Denmark

Journal: JAMA 2021 (Impact Factor 157.3)

Vallentin, M. F., Granfeldt, A., Meilandt, C., Povlsen, A. L., Sindberg, B., Holmberg, M. J., Iversen, B. N., Mærkedahl, R., Mortensen, L. R., Nyboe, R., Vandborg, M. P., Tarpgaard, M., Runge, C., Christiansen, C. F., Dissing, T. H., Terkelsen, C. J., Christensen, S., Kirkegaard, H., & Andersen, L. W. (2021). Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest. JAMA, 326(22), 2268. 

Some Background: Denmark

In 2018, Denmark had an estimated 30-day survival of 16% after out-of-hospital cardiac arrest (7). US varies from 8-16% (2).

All cardiac arrests in Denmark are responded to by an ambulance and a physician-manned mobile emergency care unit.


Administration of calcium during out-of-hospital cardiac arrest will result in improved return of spontaneous circulation.


Patients randomized to receive either 5mmol calcium or saline control

Could receive intervention via IV or IO routes

Administered immediately after first dose of epinephrine for up to 2 rounds

Primary Outcome: sustained ROSC — no further need for chest compressions x 20 minutes

Secondary Outcomes: survival at 30 days and survival at 30 days with favorable neurological outcome

Sample size calculation prior to study initiation estimated required 674 to achieve 80% power

Planned interim analysis at 50, 200, and 400 patients by independent safety monitoring committee

Inclusion Criteria

Exclusion Criteria

Data Characteristics

Outcomes and Results

19% of patients in treatment groups sustained ROSC compared to 27% in control group (primary outcome)

At 30 days, 5.2% in treatment group vs. 9.1% in control group were alive (secondary outcome)

Favorable neurological outcome at 30 days was seen in 3.6% of treatment group vs. 7.6% of control group (secondary outcome)

*Median time from cardiac arrest to administration of drug was 18 minutes



Among out-of-hospital cardiac arrests, treatment with calcium did not significantly improve sustained ROSC.