Survey of practices around the measurement and replacement of calcium in paediatric major trauma

Background

Ionised hypocalcaemia can worsen haemorrhage due to its role in clot formation, vascular tone and cardiac contractility. Current guidelines recommend maintaining normal ionised calcium levels in the bleeding trauma patient. However, guidance does not specify when to replace calcium, and for paediatric trauma, it is unclear when clinicians should measure or decide to replace calcium.

Objectives

This study aimed to survey the practices, protocols and opinions regarding the measurement and replacement of calcium in paediatric major trauma.

Methods

A cross-sectional survey with single-stage voluntary and snowball sampling. Individual emergency departments (EDs) responded to questions on departmental practices, while individual clinicians provided opinions on the measurement and replacement of calcium based on a clinical vignette with two variations (a haemodynamically stable and a haemodynamically unstable). The survey was administered using Online Surveys V3 (JISC, 2025). Respondents were invited to participate through collaborative research networks.

Results

There were responses from 67 individual EDs and 99 individual respondents from 19 different countries. Most EDs had a paediatric major haemorrhage protocol (61/67, 91.0%), but this did not include calcium for 16/67 (23.9%) of the EDs. The timing of calcium replacement was either not included or not specified in most protocols (44/67, 65.7%), with variations in when it should be replaced when specified.

Opinions on considering calcium replacement before blood products were significantly different based on whether the patient in the vignette was clinically stable or unstable. Opinions on replacement doses of exogenous calcium were significantly different when the calcium was moderately low (<1.12 mmol/L), but were not significantly different if the calcium was severely low (<1.0 mmol/L).

Conclusion

There is considerable variation among EDs regarding ionised calcium measurement and calcium replacement, both before blood product transfusion and in major haemorrhage protocols. Clinicians’ opinions on calcium measurement and replacement also vary widely. More research is needed to reach a consensus.

Level of evidence

III.