Welcome to the #MEDSHED! Needing a brief, concise review of clinical pharmacotherapy and disease management? Direct links of reference to content discussed? Look no further than the #MEDSHED series based on infographics and carousel presentations!
🚨 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.
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