Substitution of ROTEM FIBTEM A5 for A10 in trauma: an observational study building a case for more rapid analysis of coagulopathy



Rotational thromboelastometry (ROTEM®) allows guided blood product resuscitation to correct trauma-induced coagulopathy in bleeding trauma patients. FIBTEM amplitude at 10 min (A10) has been widely used to identify hypofibrinogenaemia; locally a threshold of < 11 mm has guided fibrinogen replacement. Amplitude at 5 min (A5) carries an inherent time advantage. The primary aim was to explore the relationship between FIBTEM A5 and A10 in a trauma. Secondary aim was to investigate the use of A5 as a surrogate for A10 within a fibrinogen-replacement algorithm.


Retrospective observational cohort study of arrival ROTEM results from 1539 consecutive trauma patients at a Level 1 trauma centre in Australia. Consistency of agreement between FIBTEM A5 and A10 was assessed. A new fibrinogen replacement threshold was developed for A5 using the A5–A10 bias; this was clinically compared to the existing A10 threshold.


FIBTEM A5 displayed excellent consistency of agreement with A10. Intraclass correlation coefficient = 0.972 (95% confidence interval [CI] 0.969–0.974). Bias of A5 to A10 was − 1.49 (95% CI 1.43–1.56) mm. 19.34% patients met the original local threshold of A10 < 11 mm; 19.28% patients met the new, bias-adjusted threshold of A5 < 10 mm.


ROTEM FIBTEM A5 reliably predicts A10 in trauma. This further validates use of the A5 result over A10 allowing faster decision-making in time-critical resuscitation of trauma patients. A modification of -1 to the A10 threshold might be appropriate for use with the A5 value in trauma patients.

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Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.



Rotational thromboelastometry


Amplitude at five minutes


Amplitude at ten minutes


Maximum clot firmness


Trauma-induced coagulopathy


Damage control resuscitation


Intra-class correlation


Injury severity score


Packed red cells


International normalised ratio




  1. 1.

    Roth GA, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1736–88.

    Article  Google Scholar 

  2. 2.

    Søreide K, Krüger AJ, Vårdal AL, Ellingsen CL, Søreide E, Lossius HM. Epidemiology and contemporary patterns of trauma deaths: changing place, similar pace. Older Face World J Surg. 2007;31:2092–103.

    Article  Google Scholar 

  3. 3.

    Cole E, Weaver A, Gall L, West A, Nevin D, Tallach R, et al. A decade of damage control resuscitation: new transfusion practice, new survivors, new directions. Ann Surg. 2021;273(6):1215–20.

    Article  Google Scholar 

  4. 4.

    Winearls J, Mitra B, Reade MC. Haemotherapy algorithm for the management of trauma-induced coagulopathy: an Australian perspective. Curr Opin Anesthesiol. 2017;30:265–76.

    Article  Google Scholar 

  5. 5.

    Whiting D, DiNardo JA. TEG and ROTEM: technology and clinical applications. Am J Hematol. 2014;89:228–32.

    CAS  Article  Google Scholar 

  6. 6.

    Rourke C, Curry N, Khan S, Taylor R, Raza I, Davenport R, et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost. 2012;10:1342–51.

    CAS  Article  Google Scholar 

  7. 7.

    Hagemo JS, Christiaans SC, Stanworth SJ, Brohi K, Johansson PI, Goslings JC, et al. Detection of acute traumatic coagulopathy and massive transfusion requirements by means of rotational thromboelastometry: an international prospective validation study. Crit Care. 2015;19:97.

    Article  Google Scholar 

  8. 8.

    Tapia NM, Chang A, Norman M, Welsh F, Scott B, Wall MJ, et al. TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients. J Trauma Acute Care Surg. 2013;74:378–85 (Discussion 385-386).

    CAS  Article  Google Scholar 

  9. 9.

    Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy. Ann Surg. 2016;263:1051–9.

    Article  Google Scholar 

  10. 10.

    Baksaas-Aasen K, Gall LS, Stensballe J, Juffermans NP, Curry N, Maegele M, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med. 2021;47:49–59.

    CAS  Article  Google Scholar 

  11. 11.

    Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma : fifth edition. Crit Care. 2019;23:98.

    Article  Google Scholar 

  12. 12.

    Baksaas-Aasen K, Dieren SV, Balvers K, Juffermans N, Næss P, Rourke C, et al. Data-driven development of ROTEM and TEG algorithms for the management of trauma hemorrhage: a prospective observational multicenter study. Ann Surg. 2019;270:1178–85.

    Article  Google Scholar 

  13. 13.

    Görlinger K, Dirkmann D, Solomon C, Hanke AA. Fast interpretation of thromboelastometry in non-cardiac surgery: reliability in patients with hypo-, normo-, and hypercoagulability. BJA Br J Anaesth. 2013;110:222–30 (Oxford Academic).

    Article  Google Scholar 

  14. 14.

    Dirkmann D, Görlinger K, Dusse F, Kottenberg E, Peters J. Early thromboelastometric variables reliably predict maximum clot firmness in patients undergoing cardiac surgery: a step towards earlier decision making. Acta Anaesthesiol Scand. 2013;57:594–603.

    CAS  Article  Google Scholar 

  15. 15.

    Olde Engberink RHG, Kuiper GJAJM, Wetzels RJH, Nelemans PJ, Lance MD, Beckers EAM, et al. Rapid and correct prediction of thrombocytopenia and hypofibrinogenemia with rotational thromboelastometry in cardiac surgery. J Cardiothorac Vasc Anesth. 2014;28:210–6.

    Article  Google Scholar 

  16. 16.

    Kelly JM, Rizoli S, Veigas P, Hollands S, Min A. Using rotational thromboelastometry clot firmness at 5 minutes (ROTEM® EXTEM A5) to predict massive transfusion and in-hospital mortality in trauma: a retrospective analysis of 1146 patients. Anaesthesia. 2018;73:1103–9.

    CAS  Article  Google Scholar 

  17. 17.

    von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. PLOS Med. 2007;4:e296 (Public Library of Science).

    Article  Google Scholar 

  18. 18.

    Palmer CS, Gabbe BJ, Cameron PA. Defining major trauma using the 2008 Abbreviated Injury Scale. Injury. 2016;47:109–15.

    Article  Google Scholar 

  19. 19.

    Portney LG, Watkins MP. Foundations of clinical research: applications to practice. Third. Upper Saddle River. Pearson: Prentice Hall; 2000.

    Google Scholar 

  20. 20.

    Seebold JA, Campbell D, Wake E, Walters K, Ho D, Chan E, et al. Targeted fibrinogen concentrate use in severe traumatic haemorrhage. Crit Care Resusc. 2019;21:171 (The Australasian Medical Publishing Company).

    PubMed  Google Scholar 

  21. 21.

    Ho D, Chan E, Campbell D, Wake E, Walters K, Bulmer AC, et al. Targeted cryoprecipitate transfusion in severe traumatic haemorrhage. Injury [Internet]. 2020 [cited 2020 Jul 1]; Available from:

  22. 22.

    Martin Bland J, Altman Douglas G. Statistical methods for assessing agreement between two methods of clinical measurement. The lancet. 1986;327:307–10.

    Article  Google Scholar 

  23. 23.

    Meyer ASP, Meyer MAS, Sørensen AM, Rasmussen LS, Hansen MB, Holcomb JB, et al. Thrombelastography and rotational thromboelastometry early amplitudes in 182 trauma patients with clinical suspicion of severe injury. J Trauma Acute Care Surg. 2014;76:682–90.

    Article  Google Scholar 

  24. 24.

    McGraw KO, Wong SP. Forming inferences about some intraclass correlation coefficients. Psychol Methods US Am Psychol Assoc. 1996;1:30–46.

    Google Scholar 

  25. 25.

    Schuck P. Assessing reproducibility for interval data in health-related quality of life questionnaires: Which coefficient should be used? Qual Life Res. 2004;13:571–85.

    Article  Google Scholar 

  26. 26.

    Wikkelsø A, Lunde J, Johansen M, Stensballe J, Wetterslev J, Møller AM, et al. Fibrinogen concentrate in bleeding patients. Cochrane Database Syst Rev [Internet]. John Wiley & Sons, Ltd; 2013 [cited 2020 Jun 15]; Available from:

  27. 27.

    Jensen NHL, Stensballe J, Afshari A. Comparing efficacy and safety of fibrinogen concentrate to cryoprecipitate in bleeding patients: a systematic review. Acta Anaesthesiol Scand. 2016;60:1033–42.

    CAS  Article  Google Scholar 

  28. 28.

    Curry N, Rourke C, Davenport R, Stanworth S, Brohi K. Fibrinogen replacement in trauma haemorrhage. Scand J Trauma Resusc Emerg Med. 2014;22:A5.

    Article  Google Scholar 

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Dr Ian Hughes: Office for Research Governance and Development, Gold Coast Health.


The authors declare no external funding sources.

Author information




AB consolidated the databases and wrote the manuscript. JM ran the statistical analyses. KW, EW, DH, EC, AC collected the primary data. DC facilitated the running of the study and data collection. JW led the study. All authors read and reviewed the manuscript prior to submission.

Corresponding author

Correspondence to Alexander Blayney.

Ethics declarations

Conflict of interest

The authors (Alexander Blayney, James P.A. McCullough, Elizabeth Wake, Kerin Walters, Don Campbell, Debbie Ho, Erick Chan, Aashish Chalasani and James Winearls) declare that they have no conflict of interest.

Ethical approval

This study was performed according to the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Ethics approval was obtained from the Gold Coast Hospital and Health Service Human Research Ethics Committee on the 26th March 2014 (HREC/14/QGC/17).

Informed consent

Waived consent was granted as section 2.3 of the National Statement on Ethical Conduct in Human Research.

Supplementary Information

Below is the link to the electronic supplementary material.


Supplementary Additional File 1 PDF of the local current ROTEM transfusion algorithm for critical bleeding. See “Step 2” (interpretation of FIBTEM for fibrinogen replacement). It should be noted that the exact wording of the algorithm differs slightly to that used in the report: The algorithm uses ≤ 10 mm as a threshold; this is expressed as < 11 mm in the report to facilitate direct comparison to the literature. As the outputs from the ROTEM are expressed as integers, the interpretation of these two thresholds is identical (PDF 375 KB)


Supplementary Additional File 2 PDF of the Trauma criteria used to define patients for our cohort. The local service operates a two tier trauma activation protocol: “Alert” and “Respond”. For the purposes of this study, patients meeting criteria for either tier were included in our trauma cohort (PDF 183 KB)

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Blayney, A., McCullough, J., Wake, E. et al. Substitution of ROTEM FIBTEM A5 for A10 in trauma: an observational study building a case for more rapid analysis of coagulopathy. Eur J Trauma Emerg Surg (2021).

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  • Rotational thromboelastometry
  • Fibrinogen
  • Trauma
  • Haemorrhage
  • Coagulopathy
  • Resuscitation