Page 46 - JSOM Summer 2023

Prevalence of Trauma-Induced Hypocalcemia
in the Prehospital Setting

1
2
Matt D. Brandt, MD ; Cody Liccardi ; Jennifer Heidle ;
3
Timothy D. Woods, MD ; Crystal White, RN ; J. Randolph Mullins, MD ;
6
4
5
7
Jami Blackwell, RN, MBA ; Lamanh Le, PharmD *; Kara Brantley, PharmD 9
8
ABSTRACT
Background: Recent data published by the Special Opera- Calcium measurement is often reported as either total serum
tions community suggest the Lethal Triad of Trauma should calcium or ionized calcium. The total serum calcium con-
be changed to the Lethal Diamond, to include coagulopathy, centration is divided into protein-bound (30–55%), diffus-
acidosis, hypothermia, and hypocalcemia. The purpose of this ible to organic and inorganic anions (5–15%), and ionized
study is to determine the prevalence of trauma-induced hypo- calcium (50%). Available literature suggests that using to-
calcemia in level I and II trauma patients. Methods: This is a tal serum calcium to predict ionized calcium is not accurate,
retrospective cohort study conducted at a level I trauma cen- especially in critically ill patients. A recent chart review at
3
ter and Special Operations Combat Medic (SOCM) training our institution showed that there was a low correlation of
site. Adult patients were identified via trauma services registry total adjusted calcium to ionized calcium levels when Payne’s
from September 2021 to April 2022. Patients who received formula is used to account for albumin. Because of the re-
blood products prior to emergency department (ED) arrival sult of this review, ionized calcium has been used in class
were excluded from the study. Ionized calcium levels were uti- I and II trauma patients at our institution. Class I trauma
4
lized in this study. Results: Of the 408 patients screened, 370 team activation includes full team response and the trauma
were included in the final analysis of this cohort. Hypocalce- surgeon responding to the trauma bay within 15 minutes of
mia was noted in 189 (51%) patients, with severe hypocal- notification. Class II trauma team activation includes partial
cemia identified in two (<1%) patients. Thirty-two (11.2%) team response and the trauma surgeon responding upon the
patients had elevated international normalized ratio (INR), 34 emergency physician’s request (see Supplement 1 for Trauma
(23%) patients had pH <7.36, 21 (8%) patients had elevated Classification Criteria).
lactic acid, and 9 (2.5%) patients had a temperature of <35°C.
Conclusion: Hypocalcemia was prevalent in half of the trauma Many studies have explored hypocalcemia in hypovolemic
patients in this cohort. The administration of a calcium supple- trauma patients who received blood transfusion(s) and re-
ment empirically in trauma patients from the prehospital en- ported high mortality and morbidity rates in this patient pop-
vironment and prior to blood transfusion is not recommended ulation. Vivien et al., Cherry et al., Magnotti et al., Webster
5–9
until further data prove it beneficial. et al., and Vasudeva et al. assessed ionized calcium levels in
trauma patients and reported that up to 70% of patients were
Keywords: hypocalcemia; trauma; ionized calcium; Diamond hypocalcemic upon arrival to the ED before receiving any
of Death; Lethal Triad blood products. 10–14 Despite the lack of data on the impact of
calcium in the prehosital setting, there has been discussion of
giving calcium supplemention in this enviroment to prevent
Introduction further hypocalcemic events. 15,16
Trauma is a leading cause of death, and recent data suggest The primary goal of this study was to determine the prevalence
that hypocalcemia management plays a significant role in of ionized hypocalcemia in trauma patients in the prehospital
trauma resuscitation. A literature review published in 2019 by setting prior to blood transfusion. Secondary outcomes such
the Special Operations community suggested the Lethal Triad as prevalence of coagulopathy, acidosis, and hypothermia, and
of Trauma should be changed to the Diamond of Death, to in- the relationship of injury severity score (ISS) and hypocalce-
clude coagulopathy, acidosis, hypothermia, and hypocalcemia. mia were also reviewed in this study.
Hypocalcemia, especially in the hypovolemic trauma patient
1
population, is an emerging problem. Studies dating to the
1980s confirm that hypocalcemia is one of the most common Methods
electrolyte disorders in intensive care unit (ICU) and trauma Study Design
patients; it is also associated with poor patient outcomes. 2 This observational cohort study was completed retrospectively
Calcium plays a vital role in membrane receptor activation, at a single-center, level I trauma facility and SOCM train-
hormone release, transfer of fluids between compartments, ing site affiliated with the Joint Special Operations Medical
cardiac conductivity, and coagulation. A deficiency in calcium Training Center at Fort Bragg, NC. It includes patients from
2
has been associated with increased morbidity and mortality, as a trauma services registry presenting between September 2021
well as poor coagulation, among other pathologies. 1 and April 2022 to the ED as a class I or class II trauma. All
*Correspondence to Lamanh.le@coxhealth.com
3
6
7
4
2
5
1 Dr Matt D. Brandt, Cody Liccardi, Jennifer Heidle, Dr Timothy D. Woods, Crystal White, Dr J. Randolph Mullins, Jami Blackwell,
9
8 Lamanh Le, and Kara Brantley are all affiliated with CoxHealth, Springfield, MO.
44
44