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Comparative Study
. 2025 Jan 7;20(1):2.
doi: 10.1186/s13017-024-00572-5.

Comparison of the lethal triad and the lethal diamond in severe trauma patients: a multicenter cohort

Charles Dupuy  1   2   3 , Thibault Martinez  4 , Olivier Duranteau  4 , Tobias Gauss  5 , Natacha Kapandji  6 , Jean Pasqueron  7 , Mathilde Holleville  8 , Georges Abi Abdallah  9 , Anatole Harrois  10   11 , Véronique Ramonda  12 , Delphine Huet-Garrigue  13 , Théophane Doublet  14 , Marc Leone  15 , Vincent Legros  16 , Julien Pottecher  17 , Gérard Audibert  18 , Ingrid Millot  19 , Benjamin Popoff  20 , Benjamin Cohen  21 , Fanny Vardon-Bounes  22 , Mathieu Willig  23 , Pierre Gosset  24 , Emilie Angles  25 , Nouchan Mellati  26 , Nicolas Higel  27 , Mathieu Boutonnet  4   28 , Pierre Pasquier  4   28   29 ; TraumaBase Group®
Affiliations
Comparative Study

Comparison of the lethal triad and the lethal diamond in severe trauma patients: a multicenter cohort

Charles Dupuy et al. World J Emerg Surg. .

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Keywords: Calcium; Coagulopathy; Hemorrhage; Lethal diamond; Lethal triad; Trauma.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: TraumaBase® obtained approval from the Advisory Committee for Information Processing in Health Research (CCTIRS) from the National Commission for Data Protection (CNIL) and meets national institutional review board requirements (Comité de Protection des Personnes, Paris VI, Paris, France). Data are anonymized upon collection in case report files. This study received ethical approval (CER Paris Nord, Institutional Review Board number 00006477) and was declared to the CNIL (Authorization Number 2234099). Consent for publication: Not applicable. Competing interests: Marc Leone served as a consultant for Viatris, Edwards, AOP Pharma, and MSD. Julien Pottecher for LFB. All the other authors have no conflicts of interest in relation to the submitted study.

Figures

Fig. 1
Fig. 1
Study flow chart. iCa: ionized calcium, PT ratio: prothrombin time ratio
Fig. 2
Fig. 2
ROC curves comparing the lethal triad and lethal diamond for 24-h mortality association. The areas under the curve (AUCs) of these indicators were 0.72 (95% Confidence Interval (CI) 0.69–0.74) and 0.71 (95% CI 0.68–0.74), respectively (p = 0.26)
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