Page 136 - JSOM Fall 2025

4 WakeMed, Raleigh, NC 1 University of Colorado School of Medicine, Aurora, CO
5 University of North Carolina School of Medicine, Chapel 2 Colorado School of Public Health, Aurora, CO
Hill, NC 3 Stellenbosch University, Cape Town, South Africa
6 University of Mississippi Medical Center, Jackson, MS 4 Western Cape Government Health and Wellness, Cape Town,
South Africa
Introduction
Introduction
Prehospital transfusion can improve trauma survival. Use of
cold packed red blood cells (cPRBCs) has been considered There has been increasing interest recently in the relationship
due to financial and logistic concerns. We hypothesized that between hypocalcemia and adverse outcomes in trauma. While
cPRBCs in fast-paced urban EMS would not significantly the underlying physiological mechanisms are poorly under-
contribute to hypothermia in trauma patients with severe stood, hypocalcemia is associated with increased mortality,
hemorrhage. coagulopathy, and transfusion requirement. Most studies to
date are from high-resource practice settings, where life-sav-
Methods ing interventions are more readily available than in combat
environments. Here, we describe epidemiology and outcomes
In this prospective analysis, conducted from 2021 to 2024, in-
volved trauma patients with severe hemorrhage receiving 1–2 associated with calcium derangements in a cohort of severe
units of prehospital cPRBCs at 5–7°C. trauma patients in a resource-limited healthcare system.
Methods
Results
This prospective cohort study included 1,989 subjects receiving
Eighty-two patients met inclusion criteria. Median age was 36 emergency care in the Western Cape of South Africa following
(IQR 28–46) years, 89% were male, and 82.9% experienced severe trauma for whom a serum calcium level was measured
penetrating injury with a median new injury severity score upon arrival to the hospital. Subjects were stratified by initial
(NISS) of 17 (IQR 8–27) and median initial systolic blood pres- calcium level, and covariates related to demographics, injury
sure (SBP) of 80mmHg (IQR 60–110mmHg). SBP and shock characteristics, hemodynamics, and laboratory values were
index improved significantly after transfusion (p<.001). Me- compared using either the chi-square or Kruskal-Wallis test.
dian initial temperature was 36.0°C (IQR 35.1–36.4°C) with Outcomes of interest, including mortality, length of ICU stay,
postadministration temperature of 36°C (IQR 35.0–36.3°C) and severity of organ dysfunction, were evaluated using multi-
(p=.27). Sixty-eight patients (82.9%) received 2 units of cPR- variable regression.
BCs prehospital, and 14 (17.1%) received 1 unit. Median ED
arrival temperature was 36°C (IQR 35.2–36.3°C). Among 43 Results
patients who experienced a decrease in temperature, the me-
dian change was –0.2°C [IQR –0.5 to –1.0]. Transport time The incidence of hypocalcemia was 52%, and 5% had se-
was 7 (IQR 5.9–11) minutes. After excluding prehospital car- vere hypocalcemia (iCal <1.00mmol/L). Severity of hypocal-
diac arrest (23 patients, 28%), 24-hour and hospital mortality cemia was not correlated with serum pH, lactate, creatinine,
were both 2%. or creatine kinase. Outcomes were all significantly worse in
severe hypocalcemia compared with normocalcemia (p<.01)
Discussion including 30-day mortality (4.0% vs. 2.6%), highest compos-
ite Sequential Organ Failure Assessment (SOFA) score (4 vs.
The administration of cPRBCs does not significantly decrease
patient temperatures, even in the presence of severe hemor- 2), and need for ICU admission (17% vs. 4.9%). Hypercalce-
rhage. The observed temperature stability despite the use mia was similarly associated with an increased risk of adverse
of cold blood may be attributable to improved metabolism outcomes, such as 30-day mortality (19% vs. 2.6%; p<.01)
through the restoration of perfusion and to short transport compared with normocalcemia.
times in this cohort. Though warmed blood products are Discussion
likely preferable, our findings support the safety of cPRBC use
in fast-paced EMS settings when logistical or financial con- Abnormal serum calcium is common following major trauma,
straints limit the use of blood warmers. Future research should occurring in over 50% of this population, and is associated with
explore the impact of longer transport times and varying in- multiple adverse outcomes, including mortality. It remains un-
jury mechanisms on outcomes. clear whether derangements in calcium are responsible for the
adverse events observed or are simply a marker of injury severity.
Conclusion
Administration of cPRBCs does not lead to hypothermia in Conclusion
trauma patients in a fast-paced EMS setting. Restoration of ef- Both hypocalcemia and hypercalcemia following major
fective perfusion appears to maintain body temperature when trauma were associated with increased adverse outcomes as
cPRBCs are used.
compared with those whose calcium was normal.
Mortality and Organ Failure Associated with Derangements
in Serum Calcium Following Severe Traumatic Injury Preserving the Fighting Force: An Early Mobilization
Christiaan Rees, MD, PhD ; Jessica L. Wild, PhD ; Hendrick Protocol for Faster Chest Tube Discontinuation and
1
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Lategan, MBChB, MMed ; EpiC Study Collaborators ; Julia Return to Duty in Simple Traumatic Hemothorax and
4
Dixon, MD ; MPH, Steven G. Schauer, LTC, DO, MS ; Nee- Pneumothorax 1 1
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Smitha Bhaumik, MD ; Julia Finn, MPH ; Maria Rodriguez,
Kofi Mould-Millman, MD, PhD, MSCS 1
MPH ; Hendrick Lategan, MBChB, MMed, MPH ; EpiC
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134 | JSOM Volume 25, Edition 3 / Fall 2025