Thromboelastagram and Trauma

Thromboelestagram and TraumaTrauma and accidental injuries keep us all quite busy in the Emergency Departments across the country. Unfortunately, despite advances in prevention, trauma is still the leading cause of mortality in children. Appropriately, we have discussed numerous topics pertaining to trauma (ex, Pneumothorax, Traumatic Aortic Injury, Major Brain Injury, Abdominal Trauma) and recently even touched upon the notion of Damage Control Resuscitation. One aspect of damage control resuscitation is the idea that coagulopathy is risk factor for mortality and, thus, it is important for us to understand a patient’s coagulation characteristics early on in management. Unfortunately, traditional PT/PTT and INR do not reveal the complete picture. Let’s look at a tool that may help us see that picture better – The Thromboelastagram:

 

Coagulopathy and Trauma

  • The “Terrible Triad of Trauma” = Hypothermia, Acidosis, and Coagulopathy
    • Severe hemorrhage and large volumes of saline or packed RBCs exacerbate all three aspects of this terrible triad.
      • Lots of isotonic fluids can dilute clotting factors, in addition to causing numerous other intracellular and extracellular chaos (increase inflammatory markers) complicating the patient’s physiologic status.
      • Even pRBCs can cause coagulopathy.
    • Acidosis and Coagulopathy are associated with requiring blood products. [Smith, 2016]
  • Trauma, itself, can lead to coagulopathy.
    • Patients who have had major trauma can arrive to the ED already having developed evidence of fibrinolysis and coagulopathies.
    • This can be further exacerbated by our therapies (… like lots of saline).
  • Early coagulopathy is associated with increased mortality in trauma patients (both adult and pediatric). [Strumwasser, 2016; Hendrickson, 2012; Talving, 2009; Niles, 2008; MacLeod, 2003]
    • Damage Control Resuscitation aims to reduce this effect by empirically treating coagulopathy with balanced blood product transfusions (ie, massive transfusion protocols).
      • It also focuses on using limited amounts of saline.
      • The true efficacy of massive transfusion protocols in pediatric trauma patients is still debated and broad application to all severely injured children may not be beneficial. [Cannon, 2017]
    • Empirically treating all severely injured may not be the best method to treat coagulopathy.
      • It may be better to treat those who actually have it.
      • But, PT/PTT and INR do not tell the whole story…

 

Thromboelastogram for Trauma

  • Thromboelastography (TEG) generates a Thromboelastogram [See below from Nylund, 2009].
  • TEG is a rapid, point-of-care test. [Nylund, 2009]
    • Traditional coagulation studies can take ~30-60 min to run.
    • TEG can be complete in ~10 min.
    • Point-of-care PT/PTT and INR tests do exist, but…
  • TEG measures the ENTIRE coagulation cascade. [Nylund, 2009]
    • It uses whole blood… PT/PTT and INR use just the plasma.
    • PT/PTT only evaluate part of the coagulation cascade.
    • PT/PTT does not evaluate the interaction between clotting factors and platelets.
    • PT/PTT does not assess fibrinogen or platelet function.
  • TEG is the only readily available test that assesses the fibrinolytic system.
  • Thromoboelastograms generates a tracing that can help providers tailor therapies (like FFP and Platelets) to what an individual patient may require. [Nylund, 2009]
    • Can identify the coagulopathic.
    • Can identify the patient who may benefit from anti-fibrinolytic.
    • Can identify the hypercoagulable patient also (which also can happen in the setting of trauma).
    • Each segment (ex, r-time, MA) describe specific characteristics of the clotting process (see Nylund, 2009 for nice description).

Thromboelastography

 

Moral of the Morsel

  • Clotting involves more than plasma. TEG can help you see the entire picture.
  • Coming to an ED near you… The TEG will be a tool that we need to become familiar with.

 

References

Cannon JW1, Johnson MA, Caskey RC, Borgman MA, Neff LP. High ratio plasma resuscitation does not improve survival in pediatric trauma patients. J Trauma Acute Care Surg. 2017 Aug;83(2):211-217. PMID: 28481839. [PubMed] [Read by QxMD]

Strumwasser A1, Speer AL, Inaba K, Branco BC, Upperman JS, Ford HR, Lam L, Talving P, Shulman I, Demetriades D. The impact of acute coagulopathy on mortality in pediatric trauma patients. J Trauma Acute Care Surg. 2016 Aug;81(2):312-8. PMID: 27032006. [PubMed] [Read by QxMD]

Smith SA1, Livingston MH2, Merritt NH3. Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients. J Pediatr Surg. 2016 May;51(5):848-52. PMID: 26960738. [PubMed] [Read by QxMD]

Hendrickson JE1, Shaz BH, Pereira G, Atkins E, Johnson KK, Bao G, Easley KA, Josephson CD. Coagulopathy is prevalent and associated with adverse outcomes in transfused pediatric trauma patients. J Pediatr. 2012 Feb;160(2):204-209. PMID: 21925679. [PubMed] [Read by QxMD]

Nylund CM1, Borgman MA, Holcomb JB, Jenkins D, Spinella PC. Thromboelastography to direct the administration of recombinant activated factor VII in a child with traumatic injury requiring massive transfusion. Pediatr Crit Care Med. 2009 Mar;10(2):e22-6. PMID: 19265363. [PubMed] [Read by QxMD]

Talving P1, Benfield R, Hadjizacharia P, Inaba K, Chan LS, Demetriades D. Coagulopathy in severe traumatic brain injury: a prospective study. J Trauma. 2009 Jan;66(1):55-61; discussion 61-2. PMID: 19131806. [PubMed] [Read by QxMD]

Niles SE1, McLaughlin DF, Perkins JG, Wade CE, Li Y, Spinella PC, Holcomb JB. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma. 2008 Jun;64(6):1459-63; discussion 1463-5. PMID: 18545109. [PubMed] [Read by QxMD]

MacLeod JB1, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003 Jul;55(1):39-44. PMID: 12855879. [PubMed] [Read by QxMD]

Holmes JF1, Goodwin HC, Land C, Kuppermann N. Coagulation testing in pediatric blunt trauma patients. Pediatr Emerg Care. 2001 Oct;17(5):324-8. PMID: 11673707. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. Health_Kenya says:

    What are The impacts of early thromboelastography directed therapy in trauma resuscitation.

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