Massive Hemorrhage Protocol

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Swami brings us back to a segment in EM:RAP November 2022 discussing protocol for a heavily bleeding patient beyond just a transfusion.

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Michael M. -

I used to give calcium to all of our MHP patients, but our blood bank told us that blood products don't have a significant amount of citrate anymore and so giving calcium to these patients is unnecessary. Any thought on this?

Anand S. -

From Dr. Petrosoniak:
Great question. There are some differing opinions on three general approaches for calcium administration in trauma:
1. empiric upon arrival with first unit and every 2-3 thereafter (some people think there's such a high risk of hypoCa that it should be given for all pts sick enough to need blood) not only because of the transfusion but the trauma coagulopathy inherently
2. waiting until 3-4 units given (bc then likely chelation has dropped levels)
3. waiting until labs back to decide (if you can get values back quickly, maybe this is reasonable)

What the blood bank has not taken into account is that trauma itself can cause ppl to be hypoCa. See attached article on the Lethal Diamond of trauma
My approach is typically, give after 3-4 units...unless critically ill (sBP <70-80) then I'll give a dose of Ca based on my empiric prediction that they're probably (but not definitely) hypoCa. I risk giving Ca that they're possibly hyperCa (which honestly I've never seen). In contrast Caroline Leech, an outstanding EM/trauma doc in the UK who has done work on this topic, thinks a more conservative approach is warranted and prefers option #3.

All we know for sure is that there's a proportion of trauma pts who are hypoCa immediately (who they are, we dont know precisely) and we speculate, but no definitive data that fixing the Ca helps.

That's my take and my understanding of the literature. Its really summarized thru observational (non RCT) based data.

Michael M. -


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