Management of Trauma-Induced Coagulopathy with Thrombelastography

Abstract

Viscoelastic assays, such as thrombelastography (TEG) and rotational thrombelastometry (ROTEM), have emerged as point-of-care tools that can guide the hemostatic resuscitation of bleeding injured patients. This article describes the role of TEG in contemporary trauma care by explaining this assay's methodology, clinical applications, and result interpretation through description of supporting studies to provide the reader with an evidence-based user's guide. Although TEG and ROTEM are assays based on the same viscoelastic principle, this article is focused on data supporting the use of TEG in trauma, because it is available in trauma centers in North America; ROTEM is mostly available in Europe.

Keywords: Coagulopathy; Fibrinolysis; Resuscitation; TEG; Thrombelastography; Transfusion.

Copyright © 2016 Elsevier Inc. All rights reserved.

Figures

Figure 1

TEG cup and pin design. Courtesy of the Haemoscope Corp, Niles, IL.

Figure 2

Characteristic TEG tracing. R: reaction time (R-time); K: coagulation time (K-time); MA: maximum amplitude; LY30: percent reduction in amplitude 30 minutes after reaching MA. * For the Rapid-TEG assay, R-time is replaced by ACT. Adapted from Trapani, L. Thromboelastography: Current Applications, Future Directions Open Journal of Anesthesiology (2013), 3:1, 23-27; with permission.

Figure 3

Denver Health Medical Center Goal-directed Massive Transfusion Protocol. From Einersen PM ME, Chapman MP, Moore HB, Gonzalez E, Silliman CC, Banerjee A, Sauaia A. Rapid-thromboelastography (r-TEG) thresholds for goal-directed resuscitation of patients at risk for massive transfusion. Journal of Trauma and Acute Care Surgery; with permission.

Figure 4

ROTEM-guided treatment algorithm for managing trauma-induced coagulopathy and diffuse microvascular bleeding (AUVA Trauma Hospital, Salzburg, Austria). The algorithm represents standard operating procedure for ROTEM-guided haemostatic therapy upon admission of trauma patients to the emergency room. From Schöchl H, Maegele M, Solomon C, Görlinger K, Voelckel W. Early and individualized goal-directed therapy for trauma-induced coagulopathy. Scand J Trauma Resusc Emerg Med. 2012 Feb 24;20:15; with permission.