Hypocalcaemia and traumatic coagulopathy: an observational analysis

Abstract

Background and Objectives Haemorrhage‐associated calcium loss may lead to disruption of platelet function, intrinsic and extrinsic pathway‐mediated haemostasis and cardiac contractility. Among shocked major trauma patients, we aimed to investigate the association between admission hypocalcaemia and adverse outcomes. Materials and Methods Data were extracted from the Alfred Trauma Registry and the Alfred Applications and Knowledge Management Department for all adult major trauma patients presenting directly from the scene with a shock index ≥1 from 1 July 2014 to 30 June 2018. Patients with pre‐hospital blood transfusion were excluded. Ionized hypocalcaemia was defined as <1·11 mmol/l, and acute traumatic coagulopathy was defined as initial INR >1·5. Multivariable logistic regression analysis was used to assess the association between admission hypocalcaemia and acute traumatic coagulopathy that was adjusted for Injury Severity Score, initial GCS, bicarbonate and lactate. Results There were 226 patients included in final analysis with 113 (50%) patients recording ionized hypocalcaemia on presentation prior to any blood product transfusion. Ionized hypocalcaemia was associated with coagulopathy in patients with shock index ≥1 (adjusted OR 2·9; 95% CI: 1·01–8·3, P = 0·048). Admission ionized hypocalcaemia was also associated with blood transfusion requirement in the first 24 h post‐admission in 62·5% of hypocalcaemic patients as compared to 37·5% of normocalcaemic patients (P < 0·001). Admission ionized hypocalcaemia was associated with death at hospital discharge (25·6% among hypocalcaemic patients compared to 15·0% of normocalcaemic patients (P = 0·047)). Conclusion Hypocalcaemia was a common finding in shocked trauma patients and was independently associated with acute traumatic coagulopathy. The early, protocolized administration of calcium to trauma patients in haemorrhagic shock warrants further assessment in randomized controlled trials.

Prevalence of Acute Traumatic Coagulopathy in Acutely Traumatized Dogs and Association with Clinical and Laboratory Parameters at Presentation

“…36,37 Mean ionized calcium concentrations were slightly below the RI but not significantly different between dogs with and without acute traumatic coagulopathy, despite a recent study in people showing an association between ionized hypocalcaemia and the presence of acute traumatic coagulopathy. 38 Several limitations of the study need to be discussed. Some dogs received fluid therapy or opioids prior to the first blood sampling.…”

Massive transfusions and severe hypocalcemia: An opportunity for monitoring and supplementation guidelines

“…7 The importance of calcium in coagulation is supported by studies that demonstrate coagulopathy and increased transfusion requirements in trauma patients who have ionized hypocalcemia on presentation. 8,9 Ionized hypocalcemia also decreases cardiac contractility by limiting calcium release within cardiac myocytes. 10 Furthermore, the hypothermia associated with trauma decreases liver metabolism of citrate and promotes ongoing effects of hypocalcemia.…”

“…Platelets rely on calcium for activation and stabilization into a developing thrombus 7 . The importance of calcium in coagulation is supported by studies that demonstrate coagulopathy and increased transfusion requirements in trauma patients who have ionized hypocalcemia on presentation 8, 9 . Ionized hypocalcemia also decreases cardiac contractility by limiting calcium release within cardiac myocytes 10 .…”

Low serum calcium is associated with perioperative blood loss and transfusion rate in elderly patients with hip fracture: a retrospective study

“…Consistent with the finding of total blood loss, hip fracture patients with hypocalcemia exhibited a higher blood transfusion rate, although transfusion volume difference did not reach significance. Also, trauma patients [ 22 ], and upper gastrointestinal bleeding patients [ 21 ] with hypocalcemia were most likely to receive a blood transfusion.…”

“…Hypocalcemia is a common electrolyte disorder in hospitalized patients, nearly 56.2% in trauma patients [ 18 ]. Many studies have already investigated its harmful effect, and found that hypocalcemia was associated with more bleeding or blood transfusion in patients with intracerebral hemorrhage [ 19 ], postpartum hemorrhage [ 20 ], upper gastrointestinal bleeding [ 21 ], shocked trauma [ 22 ], and total knee arthroplasty [ 23 ].…”