Page 47 - JSOM Summer 2023

laboratory data and radiographic imaging were abstracted TABLE 1 Patient Characteristics
from the Cerner Electronic Medical Record (EMR). Sample Size,
Variables n = 370
Patients Age, years, mean 51
Patients from September 2021 to April 2022 were identified Trauma Level
via the trauma services registry. Patients’ ionized calcium (iCa) Level 1, n (%) 111 (30)
levels were collected upon admission to the ED. Patients were Level 2, n (%) 264 (70)
excluded from the study if they received blood products prior Mechanism of injuries
to ED arrival, had incomplete data regarding calcium values, Trauma, n (%) 359 (97)
deceased within 24 hours of ED arrival, or were pregnant. GSW, n (%) 10 (2.7)
Other/Unknown 6
Ionized Calcium Measurement ISS 1
147 (49)
Ionized calcium was obtained from venous blood draw 1–5, n (%) 55 (18.4)
6–10, n (%)
and placed in green top tubes. All samples were run with a 11–15, n (%) 32 (10.7)
NOVA machine. The reference iCa level at our institution is 16–20, n (%) 28 (9)
1.13–1.32mmol. 21–25, n (%) 20 (6.7)
26–30, n (%) 8 (2.7)
31–35, n (%) 6 (2)
Outcomes 36–40, n (%) 1 (<1)
The primary purpose of this study is to determine the preva- >40, n (%) 1 (<1)
lence of hypocalcemia in trauma patients upon admission to Initial SBP <90mmHg, n (%) 11 (3)
the ED. Hypocalcemia was defined as ionized calcium levels Ionized calcium level, range 0.57–1.59
(iCa) <1.13mmol/L. Secondary outcomes assessed in this co- Initial PT , range 9.9–41.7
2
hort were coagulopathy, acidosis, and hypothermia. The cor- Initial INR , range 0.9–4.43
2
relation of ISS distribution and hypocalcemia is also reported.
Initial pH , range 6.93–7.55
3
4
Statistical Analysis Lactic , range 0.3–9.9
5
Descriptive statistics were utilized to illuminate data collected Temperature in °C, range 29.2–39.6
from chart reviews and are reported in terms of mean, median, ISS = injury severity score, SBP = systolic blood pressure, PT = pro-
and percentages. thrombin time, INR = international normalized ratio, GSW = gunshot
wound.
1 n = 298 for ISS; n = 286 for PT and INR; n = 147 for pH; n = 253
3
2
4
5
Results for lactic acid; n = 358 for temperature.
Of the 408 patients screened, 370 were deemed eligible for trauma patients who presented to the ED. The final analysis
inclusion for final analysis. A total of 38 patients were ex- included 10 (2.7%) patients who presented after a gunshot
cluded: 27 received blood products, two were pregnant, three wound injury, and nine (90%) patients in this subgroup were
died within 24 hours of admission, and six had inadequate found to be hypocalcemic (Table 2).
laboratory data (Figure 1). Patient characteristics included age,
trauma level (I and II), mechanism of injury, ISS, initial blood TABLE 2 Prevalence of Hypocalcemia
pressure, ionized calcium levels, initial prothrombin time (PT), Sample size, n (%), GSW, n (%),
INR, pH level, lactate level, and temperature (Table 1). Calcium Status iCa range iCa range
Normocalcemia 176 (47.6) 1 (10)
FIGURE 1 Patient selection. Hypocalcemia 189 (51) (0.76–1.12) 9 (90) (0.99–1.12)
Severe Hypocalcemia 2 (<1) NA
Hypercalcemia 3 (<1) NA
Normocalcemia iCa 1.13–1.32 mmol, hypocalcemia iCa <1.13 mmol,
severe hypocalcemia iCa <0.9 mmol, hypercalcemia iCa >1.32 mmol
GSW = gunshot wound.
In addition to hypocalcemia, we also evaluated the other ele-
ments of the Diamond of Death—coagulopathy, acidosis, and
hypothermia. In the hypocalcemia group, our data showed
that 25 (8.7%) patients had INR not within normal limit
(WNL) of 0.8–1.13; of those patients, six (2%) experienced
coagulopathy as defined INR >1.5. Twenty-two (15%) pa-
tients presented with initial pH <7.36 with only one case of
severe acidosis or pH <7.2. Seventeen (6.7%) patients had lac-
tic level greater than 2, and six (1.7%) patients experienced
hypothermia or temperature <35°C (Table 3).
Hypocalcemia was identified in 189 (51%) patients. Severe
hypocalcemia, defined as iCa <0.9mmol/L, occurred in two Figure 2 portraits ISS distribution in hypocalcemic trauma pa-
(<1%) patients. Normocalcemia was identified in 176 (47.6%) tients. Over 70% of patients in the hypocalcemia group pre-
patients, and hypercalcemia occurred in three (<1%) patients. sented with ISS of 1–15, which is categorized by Bolorunduro
17
The primary outcome of this study was to assess the preva- et al. as mild and moderate. In this study, no direct relation-
lence of hypocalcemia, which occurred in half (51%) of the ship between ISS and hypocalcemia was found.
Prehospital Trauma-Induced Hypocalcemia | 45