Check and supplement calcium levels earlier in trauma bleeding!  Our retrospective review of 1146 trauma cases revealed calcium checks often delayed or omitted, a high rate of hypocalcaemia correlating strongly with mortality and massive transfusion,
CCCF ePoster library. Kelly J. Oct 27, 2015; 117327; P87
Dr. John Kelly
Dr. John Kelly
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Topic: Retrospective or Prospective Cohort Study

Check and supplement calcium levels earlier in trauma bleeding!  Our retrospective review of 1146 trauma cases revealed calcium checks often delayed or omitted, a high rate of hypocalcaemia correlating strongly with mortality and massive transfusion, and

John Kelly, S. Rizoli, P. Dsouza

Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada | Trauma (Director), St Michael's Hospital, Toronto, Canada | Clinical Science, University of Toronto, Toronto, Canada

Introduction: We reviewed the role of calcium in the literature as an adjunct medication in massive transfusion and specifically in the prevention and treatment of trauma-induced coagulopathy (TIC). We noted the increasing use of visco-haemelastic assays such as ROTEM in the diagnosis and early management of TIC. This led to a consideration of how we could analyse changes in calcium levels after trauma and correlate these with differences in coagulation as well as outcomes such as massive transfusion and mortality.

Objectives: We wanted to explore the possibility that early calcium administration may be a safe and underused intervention in the management of bleeding in trauma. Before analysing any data we generated hypotheses to test in relation to this question, and submitted them locally.

Methods: We performed a retrospective review of 1146 consecutive severely injured trauma patients (median ISS 17) and merged a database including transfusion, ROTEM and outcome data with laboratory records including corrected serum calcium values over time. We interrogated the merged database according to the pre-defined hypotheses to see how calcium levels varied over time and how they correlated with coagulation data, transfusion data and mortality.

Results: There was a significant delay in diagnosing hypocalcaemia, as first serum calcium check was delayed a median 5 hours after initial blood work - 4 hours in patients who received transfusions. 46% of severe trauma patients, and 17-19% of all transfused/massively-transfused patients, never had their serum calcium checked at all. Hypocalcaemia was common (<2.12mmol/L, 77% of those checked), and commonly severe (<2.00mmol/L, 44%) - and correlated positively with trauma-induced coagulopathy, need for massive transfusion and mortality. In 50% of cases this hypocalcaemia was still present 48 hours after admission, i.e. any corrective treatment was inadequate. Hypercalcaemia was rare (1.5%), and that due to over-correction after documented hypocalcaemia was very rare (0.1%). Ionised calcium results and calcium administration data were unfortunately not available.

Conclusion: Hypocalcaemia is common in severe trauma and associated with coagulopathy, massive transfusion and mortality. Calcium checks are often missed or delayed in trauma patients and treatment of hypocalcaemia is often inadequate. We propose that calcium level (preferably ionized) should be checked routinely at the time of first blood draw in all severely injured or bleeding trauma patients. We advocate inclusion of a modest set dose of calcium after a certain number of units of PRBCs in massive transfusion protocols, unless blood work confirms normocalcaemia. This is likely to result in earlier treatment of many cases of undiagnosed hypocalcaemia, and the risk of hypercalcaemia is low.


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