To reduce the number of deaths caused by exsanguination, the initial management of severe trauma aims to prevent, if not limit, the lethal triad, which consists of acidosis, coagulopathy, and hypothermia. Recently, several studies have suggested adding hypocalcemia to the lethal triad to form the lethal diamond, but the evidence supporting this change is limited. Therefore, the aim of this study was to compare the lethal triad and lethal diamond for their respective associations with 24-h mortality in severe trauma patients receiving transfusion. We performed a multicenter retrospective analysis of patients in TraumaBase®, a French database (2011–2023). The patients included in this study were all trauma patients who had received transfusions of at least 1 unit of red blood cells (RBCs) within the first 6 h of hospital admission and for whom ionized calcium measurements were available. Hypocalcemia was defined as an ionized calcium level < 1.1 mmol/L. A total of 2141 severe trauma patients were included (median age: 39, interquartile range [IQR]: 26–57; median injury severity score: 27, IQR: 17–41). Patients primarily presented with blunt trauma (81.7%), and a 24-h mortality rate of 16.1% was observed. Receiver operating characteristic curve analysis revealed no significant difference in the association with 24-h mortality between the lethal diamond (area under the curve [AUC]: 0.71) and the lethal triad (AUC: 0.72) (p = 0.26). The strength of the association with 24-h mortality was similar between the lethal triad and the lethal diamond, with Cramer’s V values of 0.29 and 0.28, respectively. This study revealed no significant difference between the lethal triad and the lethal diamond in terms of their respective associations with 24-h mortality in severe trauma patients requiring transfusion. These results raise questions about the independent role of hypocalcemia in early mortality.

中文翻译：

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严重创伤患者致命三联征和致命钻石的比较：多中心队列


为了减少因失血而死亡的人数，严重创伤的初始管理旨在预防（如果不是限制）致命的三联征，包括酸中毒、凝血病和体温过低。最近，几项研究表明，在致命的三联征中加入低钙血症以形成致命的钻石，但支持这种变化的证据有限。因此，本研究的目的是比较致命三联征和致命钻石分别与接受输血的严重创伤患者 24 小时死亡率的关联。我们在法国数据库 TraumaBase® （2011-2023） 中对患者进行了多中心回顾性分析。本研究纳入的患者均为创伤患者，他们在入院后的前 6 小时内接受了至少 1 个单位的红细胞 （RBC） 输注，并且可进行离子钙测量。低钙血症定义为离子钙水平 < 1.1 mmol/L。共纳入 2141 名严重创伤患者 （中位年龄： 39， 四分位距 [IQR]： 26-57;中位损伤严重程度评分： 27， IQR： 17-41）。患者主要表现为钝挫伤 （81.7%），观察到 24 小时死亡率为 16.1%。受试者工作特征曲线分析显示，致命钻石 （曲线下面积 [AUC]： 0.71） 和致命三联征 （AUC： 0.72） 与 24 小时死亡率的相关性无显著差异 （p = 0.26）。致死三联征和致死钻石与 24 小时死亡率的关联强度相似，Cramer 的 V 值分别为 0.29 和 0.28。 这项研究表明，在需要输血的严重创伤患者中，致命三联征和致命钻石之间在各自关联 24 小时死亡率方面没有显着差异。这些结果引发了关于低钙血症在早期死亡率中的独立作用的疑问。