Massive Transfusion Protocol: Calcium Replacement - #MEDSHED

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🚨 Massive Transfusion Protocol: Calcium Replacement - #MEDSHED

🆎 Massive transfusion protocol (MTP): 10 or more packed red blood cells (PRBCs) within 24 hour period until hemorrhagic source control. Hemorrhagic shock: Permissive hypotension and limit crystalloid fluids (~ 1 L) to avoid hemodilution. Replace blood with blood. Implementation of MTP has been associated with lower rates of mortality

💥 Lethal Triad

Hypothermia, acidosis, and coagulopathy create the trauma lethal triad. Presence of the lethal triad has been associated with higher mortality and Injury Score Severity (ISS). Hemorrhagic shock is a life-threatening complication of traumas, often requiring MTP.

Calcium, MTP, and Lethal Triad

🆎 Blood products contain citrate, an anticoagulant. Citrate binds to endogenous calcium, leading to hypocalcemia and negative physiologic sequalae. Hypothermia: Decreased hepatic metabolism of citrate, worsening hypocalcemia. Worsening CO and shock. Acidosis: Hydrogen ions compete and may overcome calcium for binding sites on proteins, worsening coaulopathy. Coagulopathy: Essential for clotting factor formation and platelet function

🔥 Calcium Salt Replacement

Target ionized calcium: ~ 1 mmol/L. Give calcium chloride 1 gm IV PRN approaching each cooler (4 units) and/or to maintain target ionized calcium.

Severe hypo- (< 0.9 mmol/L) and hypercalcemia (> 1.3 mmol/L) are independently associated with lower survival rates.

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References

Hesloot D, Fitzgerald, Lefering R et al. Crit Care. 2023 Jul 6;27(1):267.

Wray JP, Bridwell RE, Schauer SG, Shackelford SA et al. Am J Emerg Med. 2021 Mar:41:104-109.

Consunji R, Elseed A, El-Menyar A et al. Blood Transfus. 2020 Nov; 18(6): 434–445.