# Initial Calcium Derangements in Major Trauma and Outcomes

## TL;DR

This study found that abnormal calcium levels upon arrival to the emergency department after major trauma are common and linked to higher mortality rates.

## Contribution

The study is the first to show that both low and high calcium levels upon trauma arrival are independently associated with increased mortality.

## Key findings

- 22% of trauma patients had low calcium levels (hypocalcemia) and 5% had high calcium levels (hypercalcemia) upon arrival.
- Hypercalcemia was associated with a 22.8% 24-hour mortality rate, higher than hypocalcemia's 11.9%.
- Mortality rates showed a U-shaped relationship with calcium levels, indicating both extremes are dangerous.

## Abstract

What is the incidence of calcium derangements upon emergency department arrival after major trauma, and are they associated with outcomes?

This cohort study found that among 1270 participants arriving to 3 level I trauma centers, 22% were hypocalcemic and 5% were hypercalcemic. Mortality at 24 hours was 11.9% for hypocalcemia, 4.3% for eucalcemia, and 22.8% for hypercalcemia.

These findings suggest that hypercalcemia was less common than hypocalcemia but was associated with worse mortality; additional research is needed to determine the underlying pathophysiology.

This cohort study examines the incidence of calcium derangements upon emergency department arrival after major trauma and associated outcomes.

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.

To determine the incidence of calcium derangements upon emergency department (ED) arrival after major trauma and associated outcomes.

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.

Major trauma and evaluation at a verified trauma center.

The primary outcome was the incidence of calcium derangements upon ED arrival. Descriptive and inferential statistics were used to compare the cohorts.

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.

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.