Shock Syndromes II

Standard coagulation laboratory or viscoelastic tests are recommended as monitoring techniques

to characterize ATC (European Trauma Guidelines, grade 1C recommendation).

Viscoelastic tests play an emerging role in screening for coagulopathy in hemorrhagic shock.

Whole blood coagulation tests that represent global clot function, including clot initiation,

formation, stabilization, and fibrinolysis, correlate well with standard plasma coagulation

studies and may be available as point-of-care tests with a faster turnaround time.

ii.

Available tests include thromboelastogram (TEG) and rotational thromboelastometry

(ROTEM), which are more commonly used in the United States and Europe, respectively.

iii.

TEG outputs include a graphic representation of clot kinetics (Figure 1 and Figure 2).

iv.

Retrospective studies show that TEG-guided resuscitation in trauma patients reduces mortality,

decreases blood product use, and helps identify hyperfibrinolysis. The ITACTIC randomized

controlled trial, involving 396 trauma patients under a massive transfusion protocol (MTP),

found no significant difference in the primary end point of days alive and free from MTP at

24 hours when comparing TEG (201 patients) with conventional tests (195 patients). Many

participants did not require extensive transfusions or meet the criteria for trauma-induced

coagulopathy, potentially influencing the study’s outcomes. However, a trend toward improved

mortality was observed in patients receiving TEG-guided care experiencing coagulopathy,

and in those with traumatic brain injury, the group receiving TEG-guided care had statistically

more days alive without MTP activation. Another smaller randomized controlled trial involving

111 trauma patients showed a higher 28-day survival rate (80.3% vs 63.6%) and reduced use

of plasma or platelets in the group receiving TEG-guided care compared with conventional

testing. This difference was apparent within the first 6 hours after trauma, suggesting that

early hemostasis guided by TEG improves survival. Although smaller than the ITACTIC trial,

this study supports a role for TEG-guided care in the treatment of trauma patients.

TEG Tracing

Interpretation

Treatment

Hypercoagulable

Enoxaparin or heparin prophylaxis

when possible

Hyperfibrinolysis

Tranexamic acid

Fibrinogen deficiency

Cryoprecipitate -or-

Concentrated fibrinogen

treatments.