Calcium and the Diamond of Death: The Critical Role of Calcium in Trauma Resuscitation
- Heather Fujawa
- 6 days ago
- 2 min read
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. But trauma science has evolved, and there’s now a fourth piece to that puzzle - hypocalcemia, turning the triangle into what we now call the Diamond of Death. Early hypocalcemia is really common in trauma patients, and it’s 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.
The Diamond of Death
Coagulopathy
Coagulopathy in trauma often starts at the time of the injury due to blood loss, and 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 make it worse. 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, which causes calcium levels to drop quickly. And that’s a big deal, 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, and 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, so citrate accumulates and continues to bind more calcium. Acidosis makes calcium less effective at the cellular level so 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, setting the stage for significant hypocalcemia, worsening coagulopathy, and crashing hemodynamics — which is why early recognition and correction are so critical in trauma resuscitation.
Trauma Nurse Priorities
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
References
Ciaraglia, F. et al. (2024). Retrospecti
ve 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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