Diagnosis and Treatment of Trauma-Induced Coagulopathy by Viscoelastography

Abstract

This article explores the application of viscoelastic tests (VETs) in trauma-induced coagulopathy and trauma resuscitation. We describe the advantages of VETs over conventional coagulation tests in the trauma setting and refer to previous disciplines in which VET use has reduced blood product utilization, guided prohemostatic agents, and improved clinical outcomes such as the mortality of critically bleeding patients. We describe different VETs and provide guidance for blood component therapy and prohemostatic therapy based on specific VET parameters. Because the two most commonly used VET systems, rotational thromboelastometry and thromboelastography, use different activators and have different terminologies, this practical narrative review will directly compare and contrast these two VETs to help the clinician easily interpret either and use the interpretation to determine hemostatic integrity in the bleeding trauma patient. Finally, we anticipate the future of new viscoelastic technologies that can be used in this setting.

Response to “Studies on hemostasis in COVID‐19 deserve careful reporting of the laboratory methods, their significance and their limitation”: Don’t throw the baby out with the bathwater

“…11,12 However, a large number of such studies already demonstrated that rotational thromboelastometry (ROTEM) can detect fibrin clot formation abnormalities, eg, factor XIII (FXIII) deficiency and abnormal fibrinolysis, eg, hyperfibrinolysis in trauma patients. [13][14][15] The test is validated and widely used in hospital laboratories. We added exogenous t-PA to improve the sensitivity of the test to hypofibrinolysis and reported the intra-and inter-assay precision of the modified assay in our hands.…”

“…The debate on the performance of different global hemostasis assays in different clinical settings is still open and needs more information from clinical studies 11,12 . However, a large number of such studies already demonstrated that rotational thromboelastometry (ROTEM) can detect fibrin clot formation abnormalities, eg, factor XIII (FXIII) deficiency and abnormal fibrinolysis, eg, hyperfibrinolysis in trauma patients 13‐15 . The test is validated and widely used in hospital laboratories.…”

Site-Of-Care Viscoelastic Assay in Major Trauma Improves Outcomes and Is Cost Neutral Compared with Standard Coagulation Tests

“…Viscoelastic monitoring using thromboelastography (TEG) is well positioned to quickly assess a patient’s coagulation profile—initial results can be obtained in as little as 10 min with full results available after 30–60 min directly at the site of care [ 29 , 30 , 31 , 32 ]. TEG is also able to guide hemostatic replacement according to individual patient needs [ 21 ] and has an advantage over conventional coagulation tests in the treatment of trauma [ 20 ]. As a result, use of TEG has been associated with improved patient outcomes, particularly reduction in mortality as demonstrated in this study.…”

“…With the development of the TEG ® 6s Hemostasis Analyzer (Haemonetics Corp., Boston, MA, USA), testing is available at the site of care providing rapid, individual patient coagulation assessment. Viscoelastic assays are thought to be more reliable than conventional clotting tests, providing a more accurate and rapid assessment of coagulopathy that is more predictive of massive transfusion needs [ 3 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ].…”

The Complexity of Trauma-Induced Coagulopathy

“…2 Hartman et al then provided an in-depth description of viscoelastic methods involving the thromboelastography and rotational thromboelastometry. 3 Trauma creates a broad spectrum of abnormal physiology, with a wide range of tissue injury and blood pressures ranging from hypertensive to asystole. Therefore, it is not surprising that a spectrum of coagulation changes is present when these severely injured patients present to the emergency department.…”