Page 46 - JSOM Winter 2025

Calcium Supplementation in
Tactical Combat Casualty Care

Riccardo De Luca, NSOCM *; Paolo Rossi, NSOCM ;
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Angelo Falcone, NSOCM 3

ABSTRACT
Calcium is vital for coagulation and hemodynamic stability, Methods
with hypocalcemia correlating to higher mortality in trauma
patients. Trauma-induced hypocalcemia is a critical issue in To conduct this review, the authors searchedPubMed for pub-
battlefield medicine, affecting both coagulation and cardiovas- lications by combining the keywords ‘hypocalcemia,’ ‘trauma,’
cular function in severely injured individuals by exacerbating ‘shock,’ ‘military,’ and ‘TCCC.’ The authors analyzed pertinent
the effects of the lethal triad. TCCC is based on strategies to abstracts and manuscripts, examined guidelines, and refer-
prevent and manage hemorrhage and shock, including the use enced sources in articles. The literature search was limited to
of blood products and the administration of calcium to avoid studies published in English, with an emphasis on emergency
citrate toxicity. However, there remains debate about whether medicine, trauma, and critical care research.
calcium supplementation should be universally recommended,
even in scenarios where blood products are unavailable. This Discussion
paper examines evidence surrounding the inclusion of cal-
cium in military trauma care protocols, weighing the benefits The Case for Calcium Supplementation
against potential risks and challenges. Calcium plays a vital role in physiological processes essential
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for survival in trauma patients. Ionized calcium (Ca ) is a crit-
ical cofactor for the coagulation cascade, directly influencing
Keywords: calcium; hypocalcemia; trauma; shock; military;
TCCC; Tactical Combat Casualty Care clot formation and stabilization of fibrin polymerization sites.
In addition, heart contractility and systemic vascular resis-
tance are low in the presence of reduced ionized calcium lev-
els, exacerbating hemodynamic instability during hemorrhagic
Introduction shock. Studies conducted mainly in civilian environments have
Within the context of TCCC, calcium’s significance has been demonstrated that hypocalcemia is prevalent among trauma
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acknowledged in preventing hypocalcemia during massive patients, even prior to the administration of blood products.
transfusion protocols. Hypocalcemia is a common complica- Hypocalcemia during the first 24h can predict mortality and
tion in trauma patients receiving blood products. Despite this the need for multiple transfusions better than the lowest fibrin- 2
understanding, the integration of calcium supplementation ogen concentrations, acidosis, and the lowest platelet counts.
within TCCC remains inconsistent, and its specific benefits in
prehospital settings require further exploration. The normal concentration of the ionized form of calcium
ranges from 1.1–1.3mmol/L and is influenced by the pH; a 0.1
In fact, a significant knowledge gap remains regarding the uni- unit increase in pH decreases the ionized calcium concentra-
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versal recommendation of calcium supplementation in austere tion by approximately 0.05mmol/L. A retrospective study on
environments or when access to blood products is limited. patients who received massive transfusion and who developed
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There is limited evidence from large-scale, controlled trials hypocalcemia (Ca <1.12) showed that severe hypocalcemia
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evaluating the independent efficacy of calcium supplementa- (Ca <0.90) was associated with a significantly higher APTT,
tion in such settings. higher blood lactate levels, lower platelet count and lower
blood pH compared with moderate hypocalcemia (Ca ≥.90).
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The purpose of this study is to evaluate the clinical evidence Patients in the Ca <0.90 group received more blood products
supporting calcium supplementation in military trauma care (34 vs. 22 units) and mortality was significantly higher (49%
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protocols, addressing its potential benefits and risks. We hy- vs. 24%).
pothesize that integrating calcium supplementation into 5
TCCC protocols, even in the absence of blood products, could Figure 1 illustrates the lethal diamond and the ways in which
enhance coagulation efficiency and improve survival outcomes co-factors can mutually exacerbate one another. In fact, re-
for combat casualties. This review aims to provide critical search on military casualties in Afghanistan showed that over
insights into optimizing trauma care strategies in resource- half of patients exhibited hypocalcemia upon arrival at for-
limited battlefield environments. ward medical facilities, correlating with higher mortality rates
*Correspondence to Rickydeluxe321@gmail.com
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1 Riccardo De Luca, Paolo Rossi, and Angelo Falcone are NATO Special Operations Combat Medics and service members in the Italian Army.
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