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Initial Calcium Derangements in Major Trauma and Outcomes
Steven G Schauer1,2,3, Susannah E Nicholson4, Julie A Rizzo5
1US Army Institute of Surgical Research, JBSA Ft Sam Houston, Ft Sam Houston, Texas.
Insights
Trauma patients frequently experience calcium imbalances upon emergency department arrival. Both hypocalcemia and hypercalcemia are linked to increased mortality and higher blood product use compared to normal calcium levels.
Area of Science:
- Trauma Care
- Emergency Medicine
- Clinical Biochemistry
Background:
- Calcium derangements are common in trauma patients, often associated with transfusions.
- Limited data exist on calcium levels upon initial trauma presentation and their impact.
- Existing evidence suggests worse outcomes for trauma patients with calcium imbalances.
Purpose of the Study:
- To determine the incidence of calcium derangements upon emergency department (ED) arrival after major trauma.
- To investigate the association between calcium derangements and patient outcomes.
Main Methods:
- Prospective, multicenter cohort study involving 1270 major trauma patients across 3 level I trauma centers.
- Ionized calcium levels were measured immediately upon ED arrival.
- Hypocalcemia, eucalcemia, and hypercalcemia were defined using a standard reference range.
Main Results:
- The incidence of calcium derangements was 22% hypocalcemia, 73% eucalcemia, and 5% hypercalcemia.
- Mortality rates at 24 hours were 11.9% for hypocalcemia, 4.3% for eucalcemia, and 22.8% for hypercalcemia.
- A U-shaped relationship was observed between calcium levels and mortality; hypercalcemia showed the worst outcomes.
Conclusions:
- Calcium derangements, including hypercalcemia, are prevalent upon ED arrival in major trauma patients.
- Both hypocalcemia and hypercalcemia are associated with increased mortality and higher blood product consumption.
- Further research, including prospective interventional trials, is needed to guide empiric treatment strategies.
Importance:
Calcium derangements frequently occur in the setting of transfusions, but limited data suggest that derangements may occur from the trauma itself. Existing data suggest worse outcomes for trauma patients who present with calcium derangements.
Objective:
To determine the incidence of calcium derangements upon emergency department (ED) arrival after major trauma and associated outcomes.
Design, Setting, And Participants:
This prospective, multicenter cohort study was conducted from 2022 to 2024 at 3 American College of Surgeons-verified level I trauma centers. All of the centers are regional receiving centers in large cities. Participants who arrived within 24 hours of injury and met the institutional criteria for the highest level of trauma activation were enrolled. Ionized calcium measurements were obtained immediately upon arrival to the ED. A normal reference range of 4.4 mg/dL to 5.2 mg/dL (to convert to millimoles per liter, multiply by 0.25) was used to define hypocalcemia, eucalcemia, and hypercalcemia.
Exposure:
Major trauma and evaluation at a verified trauma center.
Main Outcomes And Measures:
The primary outcome was the incidence of calcium derangements upon ED arrival. Descriptive and inferential statistics were used to compare the cohorts.
Results:
A total of 1270 participants (median [IQR] age, 35 [25-52] years; 999 male [79%]) were enrolled with an overall. Motor vehicle collisions followed by firearms were the most common injury mechanisms. There were 282 patients (22%) who were hypocalcemic, 925 patients (73%) who were eucalcemic, and 57 (5%) who were hypercalcemic. Mortality at 24 hours was 11.9% (34 patients) for hypocalcemia, 4.3% (40 patients) for eucalcemia, and 22.8% (13 patients) for hypercalemia. Mortality increased as the derangements became more extreme, in a U-shaped relationship. The median (IQR) injury severity score was 21 (10-29) for hypocalcemia, 14 (5-25) for eucalcemia, and 22 (13-29) for hypercalcemia. Administration of any blood product during the first 24 hours was 64.1% (184 patients) for hypocalcemia, 31.5% (291 patients) for eucalcemia, and 66.7% (38 patients) for hypercalcemia.
Conclusions And Relevance:
In this cohort study of trauma patients, hypercalcemia was less common than hypocalcemia; however, hypercalcemia was associated with worse mortality at all time points. Blood product consumption was higher among those with hypercalcemia or hypocalcemia compared with eucalcemia but was similar among those with any calcium derangement. Prospective interventional trials are needed to understand the implications of empiric treatment.
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