The Lethal Diamond of Trauma

Trauma can come in many forms, such as blunt-force, penetrating, crush, and more. In the past, aggressive fluid resuscitation was a part of many EMS protocols nationwide. Two large-bore IVs wide open were required when wheeling the injured patient into the trauma bays. The patient's systolic and diastolic blood pressures were maintained for a limited time; however, the patients were dying because we were flooding their systems with acidic normal saline in copious amounts. Now we understand that this is wrong; whole blood and RBCs, platelets, and FFP at a 1:1:1 ratio are ideal. However, we must be cognizant of a newer phenomenon referred to as hypocalcemia. The new term is the "Lethal Diamond of Trauma" due to the addition of hypocalcemia. Ionized calcium plays a huge role in supporting enzyme clotting factors and the thwarting of fibrinolysis. We will discuss how acidosis, hypothermia, coagulopathy, and hypocalcemia work together as an "axis of evil" leading to full exsanguination unless the prehospital professional intervenes with the correct procedures at the correct time. At this time, TXA is used to assist in stopping fibrinolysis and calcium gluconate and calcium chloride are used in supporting clotting factors.