Something I have been preaching for a decade has finally gotten the attention and research it deserves. On this episode, I get two of the authors from the Lethal Diamond Paper to discuss hypocalcemia in the bleeding patient.
Ricky Ditzel
Prior Special Operations Combat Medic and current Premed Postbacc Student at Columbia trying to go to medical school
Jeffrey Siegler
EM Doc & EMS Physician at Wash U in St. Louis
Read the Lethal Diamond Paper
Here is a powerpoint from Ricky
The Lethal Triad Should be the Lethal Diamond
Calcium is an independent part of the death spiral, but it is also intertwined with the other three factors as this diagram demonstrates:
Need to add citrate toxicity independently to hypocalcemia vertex
Calcium in Clotting
from @MikeEMPharmD data from: Giancarelli A, Birrer K, Alban R, Hobbs B, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202(1):182-187. [PubMed]
What to Do
- Give calcium with your first unit of blood in trauma (and TXA)
- Consider giving 1g for every 2-4 products you administer during large transfusion
- Send and Respond to Icals
Read these Papers
- MilMed
- Citrate in Cirrhotics
- Hypocalcemia during MTP
- mass trans
- Ionised-calcium-levels-in-major-trauma-patients-who-received-blood-in-the-emergency-department
- Howland WS, Schweizer O, Carlon GC, Goldiner PL. The cardiovascular effects of low levels of ionized calcium during massive transfusion. Surg Gynecol Obstet 1977; 145:581.
- Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202(1):182-187.
- Retrospective Study
Related EMCrit Stuff
- Hypocalcemia
- EMCrit 278 – Labors of Trauma – Blunt Edition (Part 1)
- EMCrit Podcast 13 – Trauma Resus II: Massive Transfusion
- Massive Transfusion Protocol (MTP)
New Stuff
- Massive transfusions and severe hypocalcemia: An opportunity for monitoring and supplementation guidelines [https://doi-org.eresources.mssm.edu/10.1111/trf.16496]
- Hypocalcemia was common in trauma patients with or without transfusion [10.1007/s00068-024-02454-6]
- Survey of practice in the UK [10.1016/j.resplu.2022.100282]
- Review of Citrate Toxicity, which may independently worsen the diamond [10.1097/CCE.0000000000000925] and hypothermia and acidosis also decrease citrate toxicity.
Now on to the Podcast…
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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It makes sense to think we should give calcium to these patients as hypocalcemia could contribute to coagulopathy. However, there is also a rationale that calcium replacement could cause celular dysfunction in septic patients, and I wonder if it could not happen to trauma patients too, as trauma patients are also inflamated, leading to more organ dysfunction. After all, we still don’t know if hypocalcemia causes worse prognosis in trauma patients or it’s just a sign of worse prognosis.
This is fantastic information and the podcast was very informative. I plan to utilize the information provided to bring this back to my unit to get people thinking more about Ca administration when they are slamming units of PRBC. Are there additional considerations I should be privy of when it comes to the CT Sx pt, or more so deviations that separate the trauma from the CT Sx pt. I feel that if someone is getting multiple units of blood, having to be reopened at the bedside/intraop, are of course acidotic, and are requiring pressors and inotropes, we should be… Read more »