Introduction

  • Trauma is a leading cause of death in the US, and uncontrolled hemorrhage is often the primary cause of mortality.
  • The lethal triad of trauma includes coagulopathy, hypothermia, and acidosis with calcium being heavily involved in the coagulation cascade.
  • Calcium plays a vital role in coagulation and platelet aggregation required by clotting factors II, VII, IX, and X, proteins C and S; and plays a role in stabilizing fibrinogen and platelets in the developing thrombus.
  • Citrate in large quantities and rapidly infused like in massive transfusion protocol (MTP), a chelating agent, is used in the Packed Red Blood Cells (PRBC's), Fresh Frozen Plasma (FFP), and other blood products to prevent calcium from interacting with the clotting factors
  • While rapidly metabolized in healthy patients, citrate clearance is reduced in hemorrhagic shock and accumulated with rapidly infused blood products commonly used in MTP.
  • Previous literature suggests that 2-15 units of blood are needed to produce a drop in calcium.
    • PropertyCalcium ChlorideCalcium Gluconate
    Dose1-2 grams1-3 grams
    AdministrationSlow IV push in emergent situations over 2-5 minutes.
    • Central line administration recommended
    • If no central line available, can use large bore IV (avoid use of hand and foot IV's)    		Slow IV push administration over 2 -5 minutes
    • May give through peripheral IV line
    Formulation100 mg/mL (10%) contains 13.6 mEq /10mL100 mg/mL (10%) contain 4.65 mEq EC/10mL
    Adverse EffectsArrythmias, bradycardia, cardiac arrest, syncope, tingling, necrosis of tissue (chloride > gluconate)
    Drug Interactions and warningsExtravasation: Calcium is a vesicant, administration into tissue can cause necrosis.
    Not to be used when patient is in ventricular fibrillation in cardiac resuscitation
    CompatibilityCompatible (Y-site): epinephrine, norepinephrine. Incompatible: sodium bicarbonate (precipitates) and blood products (do not co-administer through the same line as citrated blood; use a separate line)
    How supplied1 g/10 ml carpuject syringe or vial1g vial (100 mg/mL) and 1-2 g premix bags
    CommentsCalcium Chloride has 3x higher elemental calcium than calcium gluconate

Evidence

Author, yearDesign/ sample sizeOutcome
Vasudeva, 2020Retrospective review of trauma patients
N=226		• 50% patients recording ionized hypocalcemia on presentation prior to any blood product transfusion
• Ionized hypocalcemia was associated with coagulopathy in patients with shock index ≥1
• Admission ionized hypocalcemia was associated with death at hospital discharge 25% hypocalcemic patients vs 15% of normocalcaemic patients
Kyle, 2017Retrospective review of trauma patients
N=297		• The incidence of hypocalcemia in the non-treatment group was 70.0% vs 28.3% in the treatment group.
• In the non-treatment group, 26.6% had normal calcium levels vs 41.7% in those who received calcium.
• After only 1 unit of blood, calcium levels drop below the lower limit of normal
Giancarelli, 2016Retrospective review of trauma patients
N=156		• 97% experienced hypocalcemia and 71% had severe hypocalcemia
• Mortality was higher in the severe hypocalcemia group 49% vs 24%,
• Patients in the iCa < 0.90 mmol/L group received more blood products 34 vs 22 units
Webster, 2016Retrospective cohort analysis of trauma patients
N=55		• 55% of patients were hypocalcemic on ED arrival
• 89% patients were hypocalcemic after receiving any amount of blood product.
Magnotti, 2011Prospective cohort of trauma patients
N=591		• Low iCa levels at admission were associated with increased mortality as well as an increased need for both multiple transfusions and massive transfusion
• multivariable logistic regression analysis identified low iCa levels as an independent predictor of multiple transfusions
Vivien, 2005Prospective cohort of trauma patients
N=212		• A normal iCa concentration was observed in 56 (26%) patients, a mild ionized hypocalcemia in 135 (64%) patients, and a severe iCa in 21 (10%) patients.
• There was a significant correlation between iCa concentration with the amount of infused blood products

Conclusions

ionized calcium levels during resuscitation

References

  • Calcium chloride. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved June 17, 2020, from http://www.micromedexsolutions.com/
  • Vasudeva M, et al. Hypocalcaemia and traumatic coagulopathy: an observational analysis. Vox Sang. 2020;115(2):189-195. doi:10.1111/vox.12875
  • Giancarelli A, et al. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016 May; 202(1):182-187.
  • Kyle T, et al. Emerg Med J. 2018;35(3):176-179. doi:10.1136/emermed-2017-206717
  • Giancarelli A, et al. J Surg Res. 2016;202(1):182-187. doi:10.1016/j.jss.2015.12.036
  • Webster S, et al. Emerg Med J. 2016;33(8):569-572. doi:10.1136/emermed-2015-205096
  • Magnotti LJ, et al. J Trauma. 2011;70(2):391-397.
  • Vivien B, et al. Crit Care Med. 2005;33(9):1946-1952. doi:10.1097/01.ccm.0000171840.01892.36
  • Ditzel RM, et al. J Trauma Acute Care Surg. 2020;88(3):434-43
Tags:hypocalcemia trauma calcium massive transfusion