Lethal Diamond

Lethal Diamond

Lethal Diamond

Info from header image by the EMCrit Project, in particular this article talking about how the "Lethal Triad" needs to turn into the "Lethal Diamond."

Let’s take a look at an awesome article focused on a hot topic in prehospital trauma. Read the full article at the Journal of Trauma and Acute Care Surgery. For a long time, we have focused on the lethal triad (Hypothermia, Acidosis and Coagulopathy) in trauma patients. Evidence has shown that HYPOCALCEMIA may play a role in mortality of trauma patients. By incorporating HYPOCALCEMIA into the lethal triad, changing it to a diamond, the authors propose that we may affect outcomes by treating HYPOCALCEMIA up front.

Hypothermia Acidosis
Decreases platelet aggregation, reduces local vasoconstriction, alters enzyme activity in the coagulation cascade, causes leftward shift in oxygen-hemoglobin dissociation curve. Reduces coagulation factor activity, increases fibrin degradation rate, increases bleeding times. Lower levels of calcium increase acidosis.
Coagulopathy Trauma related Hypocalcemia
The failure of blood from the above mechanisms. Extrinsic, Intrinsic clotting pathways rely on calcium so coagulopathy worsens with hypocalcemia. Decreases cardiac contractility(hypotension). Studies show it occurs in over half of all trauma patients. Hypocalcemia nearly doubles mortality.

Additionally, Blood Transfusions can worsen hypocalcemia by infusing citrate (calcium binder). 97% of massive transfusion trauma patients become hypocalcemic. Interesting note: packed RBCs contain approximately twice the amount of citrate as Whole Blood.

Treatment: Administering Calcium (10ml Ca Chloride) prehospital can decrease hypocalcemia from 70% to 28%.

JTS Guideline: Administer 1gm Ca up front and then with every 4 units of blood products.

Problem: We don’t know if treating hypocalcemia affects outcome. It makes sense to treat hypocalcemia up front (prehospital) so we should, but we need studies to confirm if it makes a difference.

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