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Calcium and the Diamond of Death: The Critical Role of Calcium in Trauma Resuscitation

Updated: Jan 5

The Critical Role of Calcium in Trauma Care


In trauma resuscitation, most of us know about the Trauma Triad of Death—hypothermia, acidosis, and coagulopathy. However, trauma science has evolved. There’s now a fourth piece to that puzzle - hypocalcemia. This addition transforms the triangle into what we now call the Diamond of Death. Early hypocalcemia is common in trauma patients. It is strongly linked with higher transfusion needs, worse coagulopathy, and increased mortality. In other words, if we don’t pay attention to calcium early, our patients can spiral fast.


graphic diamond of hypocalcemia, acidosis, coagulopathy, and hypothermia

The Diamond of Death


Coagulopathy


Coagulopathy in trauma often starts at the time of the injury due to blood loss. Hypothermia and acidosis worsen it. Excessive crystalloid infusion disrupts clot formation. Balanced resuscitation and early blood products are essential. Coagulopathy contributes to the leading cause of preventable death in trauma: uncontrolled bleeding.


Control Volume

  • Control hemorrhage.

  • Begin balanced resuscitation with 1:1:1 PRBC's:FFP:Platelets (or per local protocol).


Acidosis


Acidosis causes weaker clots and significantly prolongs clotting time. Although acidosis often develops as a result of shock and inadequate tissue perfusion, resuscitation decisions can unintentionally worsen it. Administering large volumes of normal saline—which has a low pH (around 5.5) and a high chloride concentration—can contribute to hyperchloremic acidosis and further destabilize the patient.


Stabilize pH

  • Limit crystalloid infusions.

  • Prioritize blood administration.


Hypothermia


Many trauma patients arrive already hypothermic due to prolonged extrication, environmental exposure, spinal cord injury, or major burns. Obtaining and documenting a core temperature early is an essential step in addressing this element.


Prevent Further Heat Loss

  • Warm the room. The trauma bay should be kept between 80-85 degrees.

  • Use active warming blankets/devices.

  • Warm IV fluids and blood products.


Hypocalcemia


During a massive transfusion, the citrate in stored blood binds to ionized calcium, causing calcium levels to drop quickly. This is significant because calcium is Factor IV in the clotting cascade. Calcium is also necessary for cardiac contractility and vascular regulation. When patients become hypocalcemic early in trauma resuscitation, their outcomes are significantly worse. Research shows it’s an independent predictor of mortality.


Optimize Calcium

  • Assess calcium levels prior to MTP initiation.

  • Replace calcium according to local protocols.


So how do the elements of the traditional Trauma Triad impact hypocalcemia? When patients are hypothermic, the liver's ability to clear citrate is impaired. Citrate accumulates and continues to bind more calcium. Acidosis makes calcium less effective at the cellular level. Even if the calcium level isn't critical, the body responds as though it is. Add in massive transfusion, and now even more citrate is entering the system. This sets the stage for significant hypocalcemia, worsening coagulopathy, and crashing hemodynamics. This is why early recognition and correction are so critical in trauma resuscitation.


Trauma Nurse Priorities


As trauma nurses, we have specific priorities to ensure optimal patient outcomes. Here are key actions to take:


  • Obtain baseline ionized calcium.

  • Replace calcium proactively during massive transfusion per protocol.

  • Limit unnecessary crystalloid volume.

  • Maintain active warming measures.

  • Monitor for refractory hypotension, arrhythmias, or persistent bleeding.


nurse holding a unit of blood

Conclusion


In conclusion, understanding the critical role of calcium in trauma care is essential. The integration of hypocalcemia into the Trauma Triad of Death highlights the need for vigilance in monitoring and managing calcium levels. By prioritizing calcium optimization and addressing the factors that contribute to coagulopathy, acidosis, and hypothermia, we can significantly improve patient outcomes.


References

Ciaraglia, F. et al. (2024). Retrospective analysis of the effects of hypocalcemia in severely injured trauma patients.

Vasudeva, M. et al. (2021). Hypocalcemia in trauma patients: A systematic review.

Vettorello, F. et al. (2022). Early hypocalcemia in severe trauma: An Independent Predictor of Mortality.


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