Skip to main content

Advertisement

SpringerLink
Log in

Coagulation Management in Trauma: Do We Need a Viscoelastic Hemostatic Assay?

  • Blood Management (KA Tanaka, Section Editor)
  • Published:
Current Anesthesiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Coagulopathy is present in nearly 25% of severely injured patients and increases significantly with administration of massive transfusion of blood products. The cell-based model of hemostasis provides a background on which the current understanding of Acute Traumatic Coagulopathy (ATC) is managed.

Recent Findings

Viscoelastic Hemostatic Assays (VHAs) generate results that identify severely injured trauma patients at risk for large-volume blood transfusion, coagulation deficiencies, and increased mortality that are available more quickly than Conventional Coagulation Tests (CCTs). Viscoelastic-guided resuscitation during hemorrhage was recently described and demonstrated no difference in 24-h survival and free of massive transfusion.

Summary

VHAs are potentially valuable in early detection of patients at risk for massive resuscitation and severe coagulopathy. This review will address the ACT, clinical data supporting VHA utilization in trauma patients, and limitations in scientific knowledge of viscoelastic testing.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Simmons JW, Powell MF. Acute traumatic coagulopathy: pathophysiology and resuscitation. Br J Anaesth. 2016;117(suppl 3):iii31–43.

    Article  CAS  PubMed  Google Scholar 

  2. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Tisherman SA, Schmicker RH, Brasel KJ, Bulger EM, Kerby JD, Minei JP, et al. Detailed description of all deaths in both the shock and traumatic brain injury hypertonic saline trials of the Resuscitation Outcomes Consortium. Ann Surg. 2015;261(3):586–90.

    Article  PubMed  Google Scholar 

  4. Yang S, Mackenzie CF, Rock P, Lin C, Floccare D, Scalea T, et al. Comparison of massive and emergency transfusion prediction scoring systems after trauma with a new Bleeding Risk Index score applied in-flight. J Trauma Acute Care Surg. 2021;90(2):268–73.

    Article  PubMed  Google Scholar 

  5. Inaba K, Siboni S, Resnick S, Zhu J, Wong MD, Haltmeier T, et al. Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg. 2015;79(2):232–7 (quiz 332-3).

    Article  PubMed  Google Scholar 

  6. Qasim ZA, Sikorski RA. Physiologic considerations in trauma patients undergoing resuscitative endovascular balloon occlusion of the aorta. Anesth Analg. 2017;125(3):891–4.

    Article  PubMed  Google Scholar 

  7. Hanna K, Bible L, Chehab M, Asmar S, Douglas M, Ditillo M, et al. Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma. J Trauma Acute Care Surg. 2020;89(2):329–35.

    Article  CAS  PubMed  Google Scholar 

  8. Pivalizza EG, Stephens CT, Sridhar S, Gumbert SD, Rossmann S, Bertholf MF, et al. Whole blood for resuscitation in adult civilian trauma in 2017: a narrative review. Anesth Analg. 2018;127(1):157–62.

    Article  PubMed  Google Scholar 

  9. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127–30.

    Article  PubMed  Google Scholar 

  10. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55(1):39–44.

    Article  PubMed  Google Scholar 

  11. Gaessler H, Helm M, Kulla M, Hossfeld B, Schmid U, Kerschowski J, et al. Prehospital evaluation and detection of induced coagulopathy in trauma: the PREDICT study. J Trauma Acute Care Surg. 2021;91(2):344-51. Prospective observational study of 148 patients with blood samples obtained at the scene of injury. Patietns were classfiied as having no prehospital coagulopathy, coagulopathy, or coagulopathy and hyperfibrinolysis. Prehospital coagulopathy and hyperfibrinolysis was present in 6.1% and assocaied with significantly increased mortality.

  12. Cotton BA, Faz G, Hatch QM, Radwan ZA, Podbielski J, Wade C, et al. Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma. 2011;71(2):407–14 (discussion 14-7).

    PubMed  Google Scholar 

  13. Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, et al. Trauma-induced coagulopathy. Nat Rev Dis Primers. 2021;7(1):30.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Hoffman M, Monroe DM 3rd. A cell-based model of hemostasis. Thromb Haemost. 2001;85(6):958–65.

    Article  CAS  PubMed  Google Scholar 

  15. Savage B, Saldivar E, Ruggeri ZM. Initiation of platelet adhesion by arrest onto fibrinogen or translocation on von Willebrand factor. Cell. 1996;84(2):289–97.

    Article  CAS  PubMed  Google Scholar 

  16. Levy JH, Szlam F, Tanaka KA, Sniecienski RM. Fibrinogen and hemostasis: a primary hemostatic target for the management of acquired bleeding. Anesth Analg. 2012;114(2):261–74.

    Article  CAS  PubMed  Google Scholar 

  17. Fries D, Martini WZ. Role of fibrinogen in trauma-induced coagulopathy. Br J Anaesth. 2010;105(2):116–21.

    Article  CAS  PubMed  Google Scholar 

  18. McQuilten ZK, Wood EM, Bailey M, Cameron PA, Cooper DJ. Fibrinogen is an independent predictor of mortality in major trauma patients: a five-year statewide cohort study. Injury. 2017;48(5):1074–81.

    Article  PubMed  Google Scholar 

  19. Hagemo JS, Stanworth S, Juffermans NP, Brohi K, Cohen M, Johansson PI, et al. Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study. Crit Care. 2014;18(2):R52.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Moore HB, Moore EE, Neal MD, Sheppard FR, Kornblith LZ, Draxler DF, et al. Fibrinolysis shutdown in trauma: historical review and clinical implications. Anesth Analg. 2019;129(3):762–73.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Jones CP, Keene DD, Nordmann GR. Viscoelastic testing of coagulation. Int Anesthesiol Clin. 2017;55(3):96–108.

    Article  PubMed  Google Scholar 

  22. Gorlinger K, Perez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud AAP, et al. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol. 2019;72(4):297–322.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  23. Tanaka KA, Bolliger D, Vadlamudi R, Nimmo A. Rotational thromboelastometry (ROTEM)-based coagulation management in cardiac surgery and major trauma. J Cardiothorac Vasc Anesth. 2012;26(6):1083–93.

    Article  PubMed  Google Scholar 

  24. Gonzalez E, Moore EE, Moore HB. Management of trauma-induced coagulopathy with thrombelastography. Crit Care Clin. 2017;33(1):119–34.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Harr JN, Moore EE, Ghasabyan A, Chin TL, Sauaia A, Banerjee A, et al. Functional fibrinogen assay indicates that fibrinogen is critical in correcting abnormal clot strength following trauma. Shock. 2013;39(1):45–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Cotton BA, Harvin JA, Kostousouv V, Minei KM, Radwan ZA, Schochl H, et al. Hyperfibrinolysis at admission is an uncommon but highly lethal event associated with shock and prehospital fluid administration. J Trauma Acute Care Surg. 2012;73(2):365–70 (discussion 70).

    Article  CAS  PubMed  Google Scholar 

  27. Holcomb JB, Minei KM, Scerbo ML, Radwan ZA, Wade CE, Kozar RA, et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients. Ann Surg. 2012;256(3):476–86.

    Article  PubMed  Google Scholar 

  28. Meyer AS, Meyer MA, Sorensen 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(3):682–90.

    Article  PubMed  Google Scholar 

  29. Khan M, Jehan F, Bulger EM, O’Keeffe T, Holcomb JB, Wade CE, et al. Severely injured trauma patients with admission hyperfibrinolysis: is there a role of tranexamic acid? Findings from the PROPPR trial. J Trauma Acute Care Surg. 2018;85(5):851–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Chapman MP, Moore EE, Moore HB, Gonzalez E, Morton AP, Chandler J, et al. The “Death Diamond”: rapid thrombelastography identifies lethal hyperfibrinolysis. J Trauma Acute Care Surg. 2015;79(6):925–9.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Baksaas-Aasen K, Van Dieren S, Balvers K, Juffermans NP, Naess PA, 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(6):1178-85. Prospective, multi-center observational study to develop a data-driven algorithm for management of traumatic coagulopathy. 2,287 patients were enrolled and traumatic coagulopathy was identified by EXTEM CA5 <30mm and rTEG-FF MA <46mm with 80% sensitivity.

  32. 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  PubMed  PubMed Central  Google Scholar 

  33. Stettler GR, Sumislawski JJ, Moore EE, Nunns GR, Kornblith LZ, Conroy AS, et al. Citrated kaolin thrombelastography (TEG) thresholds for goal-directed therapy in injured patients receiving massive transfusion. J Trauma Acute Care Surg. 2018;85(4):734–40.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Tauber H, Innerhofer P, Breitkopf R, Westermann I, Beer R, El Attal R, et al. Prevalence and impact of abnormal ROTEM(R) assays in severe blunt trauma: results of the “Diagnosis and Treatment of Trauma-Induced Coagulopathy (DIA-TRE-TIC) study.” Br J Anaesth. 2011;107(3):378–87.

    Article  CAS  PubMed  Google Scholar 

  35. Schochl H, Cotton B, Inaba K, Nienaber U, Fischer H, Voelckel W, et al. FIBTEM provides early prediction of massive transfusion in trauma. Crit Care. 2011;15(6):R265.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Ives C, Inaba K, Branco BC, Okoye O, Schochl H, Talving P, et al. Hyperfibrinolysis elicited via thromboelastography predicts mortality in trauma. J Am Coll Surg. 2012;215(4):496–502.

    Article  PubMed  Google Scholar 

  37. Kashuk JL, Moore EE, Sawyer M, Wohlauer M, Pezold M, Barnett C, et al. Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma. Ann Surg. 2010;252(3):434–42 (discussion 43-4).

    Article  PubMed  Google Scholar 

  38. David JS, Lambert A, Bouzat P, Incagnoli P, Geay-Baillat AM, Taverna XJ, et al. Fibrinolytic shutdown diagnosed with rotational thromboelastometry represents a moderate form of coagulopathy associated with transfusion requirement and mortality: a retrospective analysis. Eur J Anaesthesiol. 2020;37(3):170–9.

    Article  PubMed  Google Scholar 

  39. Moore EE, Moore HB, Gonzalez E, Sauaia A, Banerjee A, Silliman CC. Rationale for the selective administration of tranexamic acid to inhibit fibrinolysis in the severely injured patient. Transfusion. 2016;56(Suppl 2):S110–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Moore HB, Moore EE, Gonzalez E, Chapman MP, Chin TL, Silliman CC, et al. Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance to antifibrinolytic therapy. J Trauma Acute Care Surg. 2014;77(6):811–7 (discussion 7).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Moore HB, Moore EE, Liras IN, Gonzalez E, Harvin JA, Holcomb JB, et al. Acute fibrinolysis shutdown after injury occurs frequently and increases mortality: a multicenter evaluation of 2,540 severely injured patients. J Am Coll Surg. 2016;222(4):347–55.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Cardenas JC, Wade CE, Cotton BA, George MJ, Holcomb JB, Schreiber MA, et al. TEG lysis shutdown represents coagulopathy in bleeding trauma patients: analysis of the PROPPR cohort. Shock. 2019;51(3):273-83. Secondary analysis of PROPPR trial that evaluated fibrinolysis by low (<0.9%), moderate (0.9%-2.9%), or high (>2.9%) LY-30; and D-dimer and Plasmin-Antiplasmin (PAP) levels. Patients with low fibrinolysis had elevated D-dimer and PAP, suggesting a coagulopathy associated with poor outcomes.

  43. Laursen TH, Meyer MAS, Meyer ASP, Gaarder T, Naess PA, Stensballe J, et al. Thrombelastography early amplitudes in bleeding and coagulopathic trauma patients: results from a multicenter study. J Trauma Acute Care Surg. 2018;84(2):334-41. Prospective observational study at two trauma centers with 404 patients with suspicion for severe injury. Thromboelastography amplitudes at 5 and 10 minutes were significantly associated with mortality.

  44. Taylor JR 3rd, Fox EE, Holcomb JB, Rizoli S, Inaba K, Schreiber MA, et al. The hyperfibrinolytic phenotype is the most lethal and resource intense presentation of fibrinolysis in massive transfusion patients. J Trauma Acute Care Surg. 2018;84(1):25–30.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Raza I, Davenport R, Rourke C, Platton S, Manson J, Spoors C, et al. The incidence and magnitude of fibrinolytic activation in trauma patients. J Thromb Haemost. 2013;11(2):307–14.

    Article  CAS  PubMed  Google Scholar 

  46. Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2016;263(6):1051–9.

    Article  PubMed  Google Scholar 

  47. Innerhofer P, Fries D, Oswald E, group Rs. Early fibrinogen-concentrate administration in management of trauma-induced coagulopathy — authors’ reply. Lancet Haematol. 2017;4(8):e348–9.

    Article  PubMed  Google Scholar 

  48. Bugaev N, Como JJ, Golani G, Freeman JJ, Sawhney JS, Vatsaas CJ, et al. Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;89(6):999–1017.

    Article  PubMed  Google Scholar 

  49. 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(1):49-59. Prospective, multi-center, randomized trial of viscoelastic hemostatis assays versus conventional coagulation test-guided resuscitation. There was no difference in 24-survival free of massive transfusion or 28-day mortality.

  50. Brill JB, Brenner M, Duchesne J, Roberts D, Ferrada P, Horer T, et al. The role of TEG and ROTEM in damage control resuscitation. Shock. 2021;56(1S):52–61.

  51. CRASH-2 Collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23–32.

    Article  CAS  Google Scholar 

  52. Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic therapy and perioperative considerations. Anesthesiology. 2018;128(3):657–70.

    Article  CAS  PubMed  Google Scholar 

  53. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) study. Arch Surg. 2012;147(2):113–9.

    Article  CAS  PubMed  Google Scholar 

  54. Morrison JJ, Ross JD, Dubose JJ, Jansen JO, Midwinter MJ, Rasmussen TE. Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: findings from the MATTERs II Study. JAMA Surg. 2013;148(3):218–25.

    Article  CAS  PubMed  Google Scholar 

  55. Diebel ME, Martin JV, Liberati DM, Diebel LN. The temporal response and mechanism of action of tranexamic acid in endothelial glycocalyx degradation. J Trauma Acute Care Surg. 2018;84(1):75–80.

    Article  CAS  PubMed  Google Scholar 

  56. Dixon AL, McCully BH, Rick EA, Dewey E, Farrell DH, Morrison LJ, et al. Tranexamic acid administration in the field does not affect admission thromboelastography after traumatic brain injury. J Trauma Acute Care Surg. 2020;89(5):900-7. Secondary analysis from a prospective, randomized trial of difference doses of pre-hospital tranexamic acid (placebo bolus vs 1gm bolus with 1gm infusion vs 2 gm bolus) in patients with suspected traumatic brain injury. There were no differences in TEG values among study groups.

  57. Guyette FX, Brown JB, Zenati MS, Early-Young BJ, Adams PW, Eastridge BJ, et al. Tranexamic acid during prehospital transport in patients at risk for hemorrhage after injury: a double-blind, placebo-controlled, randomized clinical trial. JAMA Surg. 2020. Prospective, multi-center, randomized trial of pre-hospital tranexamic acid in patients with suspected hemorrhage. THere was no difference in 30-day mortality (8.1% vs 9.9%, p = 0.17). However, there was significantly lower mortality in patients that received TXA within 1-hout (4.6% vs 7.6%, p < 0.002) and patients with systolic blood pressure <70 mmHg (18.5% vs 35.5%, p < 0.003).

  58. Li SR, Guyette F, Brown J, Zenati M, Reitz KM, Eastridge B, et al. Early prehospital tranexamic acid following injury is associated with a 30-day survival benefit: a secondary analysis of a randomized clinical trial. Ann Surg. 2021;274(3):419–26.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Divisions of Trauma Anesthesiology and Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, T1R7721201, USA

    Justin E. Richards

  2. Department of Anesthesiology, Critical Care Medicine, University of Cincinnati College of Medicine, Medical Sciences Building, Room 3502 (Mail Location: 0531), 231 Albert Sabin Way, P.O. Box 670531, Cincinnati, OH, 45267-0531, USA

    Benjamin T. Fedeles

Authors
  1. Justin E. Richards
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Benjamin T. Fedeles
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Justin E. Richards.

Ethics declarations

Conflict of Interest

Justin E. Richards and Benjamin T. Fedeles declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Blood Management

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Richards, J.E., Fedeles, B.T. Coagulation Management in Trauma: Do We Need a Viscoelastic Hemostatic Assay?. Curr Anesthesiol Rep 12, 277–285 (2022). https://doi.org/10.1007/s40140-022-00532-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40140-022-00532-2

Keywords

Search

Navigation