Page 47 - JSOM Winter 2025

FIGURE 1 Calcium and its relationship to individual components of the traditional lethal triad demonstrated as the diamond of death.

THE ROLE OF CALCIUM IN THE DIAMOND OF DEATH

HYPOTHERMIA:
Decreased hepatic metabolism of citrate precipitates hypocalcemia.
Hypocalcemia is associated with decreased cardiac output and shock.

ACIDOSIS: Diamond COAGULOPATHY:
Hypocalcemia is associated with of Calcium is critical for proper platelet
acidosis which in turn worsens coagulopathy. function and coagulation. Hypocalcemia
Death is directly associated with impaired
coagulation in trauma patients.

HYPOCALCEMIA:
Hypocalcemia develops from trauma and hemorrhage which is worsened by transfusion.

and prolonged coagulopathy. This condition is correlated risk of transfusing unscreened blood. Moreover, this practice
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with worse outcomes, including increased mortality and pro- remains the prerogative of medics in Special Forces, leaving
longed coagulopathy. Early supplementation of calcium, ad- conventional troops virtually without access to blood trans-
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ministered IV as calcium chloride or calcium gluconate, has fusions and/or their components on the battlefield. Therefore,
been shown to improve coagulation efficiency and stabilize we emphasize the importance of equipping as many medics as
hemodynamics, reducing the risk of death. To correct hypo- possible with effective and easy-to-use tools. Such as the in-
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calcemia, calcium chloride is preferred to calcium gluconate, troduction of tranexamic acid into international protocols to
as 10% calcium chloride contains 270mg of elemental calcium counteract hemorrhages; it has been estimated to reduce mor-
per 10mL, whereas 10% calcium gluconate contains 90mg tality by 1%–2%. Similarly, we believe that the integration
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of elemental calcium per 10mL. Calcium chloride offers the of calcium into the TCCC protocols could ensure a slight in-
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advantage of delivering a higher concentration of elemental crease in the survival rates of severely injured trauma patients.
calcium per dose compared to calcium gluconate, making it
more effective for rapidly correcting severe hypocalcemia. Ad- Potential Risks and Limitations
ditionally, in cases of trauma or compromised liver function, Despite its apparent benefits, the routine use of calcium in
calcium chloride is absorbed more quickly, providing faster trauma care is not without challenges. One concern is appro-
physiological effects. However, its use requires caution as it priate dosing protocols, particularly in prehospital military set-
carries a higher risk of tissue necrosis if extravasation occurs tings where diagnostic tools to monitor ionized calcium levels
due to a dislodged IV or intraosseous catheter. 10 may be unavailable. Excessive calcium supplementation may
lead to increased serum calcium levels and has been associated
Current military guidelines recommend administering 1g of with adverse cardiovascular outcomes, including myocardial
calcium after the first unit of blood product, followed by an infarction. Clinically significant hypercalcemia is known to
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additional gram after every 4 units of blood products. 11 cause neuromuscular dysfunction and cardiac arrhythmias.
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A retrospective analysis of patient data showed no statistically
Moreover, the operational context of military environments, significant differences between the lethal triad and lethal dia-
where rapid access to advanced care may be limited, further mond regarding their associations with mortality. 16
underscores the value of simple, field-deployable interventions
like calcium supplementation. Administering calcium as part Additionally, some critics argue that the clinical evidence sup-
of the initial resuscitation process could mitigate hypocalce- porting calcium supplementation in trauma care remains lim-
mia-related complications, even when blood products are un- ited. While observational studies highlight the prevalence and
available, and enhance overall survival rates. 12 impact of hypocalcemia, there is a lack of large-scale, random-
ized controlled trials directly evaluating the efficacy of rou-
This addition to the protocol would be advantageous in na- tine calcium administration in improving trauma outcomes.
tions where access to blood or blood products (such as red This absence of robust, high-quality data has led to hesitancy
blood cells, platelets, and plasma) is limited due to logistical among the medical community to adopt calcium supplemen-
difficulties or restrictive transfusion regulations. Although tation universally. 17
field blood transfusion significantly increases the chances of
survival, its effectiveness is greatly enhanced the faster it is ad- Carrying calcium gluconate or calcium chloride in austere
ministered. Therefore, in countries where soldiers have limited environments also presents limitations related to storage
access to cold-stored whole blood, field transfusion remains an conditions. According to USP (United States Pharmacopeia)
option, with all its challenges: possibility of failure, high level guidelines, these medications should be stored at 20 to 25°C
of specialization required, need for constant skill training, and (68–77°F), with excursions permitted between 15 and 30°C

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