Hypocalcemia in Trauma Resuscitation

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.

Properties

Calcium Chloride

Calcium Gluconate

Dose

1-3 grams

1-3 grams

Administration

Slow IV push in emergent situations

over 2-5 minutes.

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,

2016

Retrospective

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 group received more blood products 34 vs 22 units

Webster,

2016

Retrospective

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,

2011

Prospective

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,

2005

Author, year

Design/ sample

size

Outcome

Vasudeva,

2020

Retrospective

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, 2017

Retrospective

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,

2016

Retrospective

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%,

ionized calcium levels during resuscitation

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.12875Giancarelli 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

• Cause decrease in liver metabolism of citrate
• Citrate not metablolized in the liver binds to Ca2+ leading to less Ca2+ available in

the blood

Hypothermia

• Low Ca2+ levels associated with low pH
• Lower pH prolongs clot formation

Acidosis

• Ca2+ in the plasma is necesarry co-factor for clotting

Coagulopathy

• Ca2+ levels drop due to blood loss
• Transfusion further exacerbates

Hypocalcemia