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Cited by 58Trauma, Hemostasis, Coagulopathy, ResuscitationBlood transfusion and managementHemostasis and retained surgical items

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Targeted Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy in Traumatic and Acquired Coagulopathy

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Walsh, Mark, Fritz, Stephanie, Hake, Daniel, Son, Michael, Greve, Sarah, Jbara, Manar, Chitta, Swetha, Fritz, Braxton, Miller, Adam, K Bader, Mary, McCollester, Jonathon, Binz, Sophia, Liew-Spilger, Alyson, Thomas, Scott, Crepinsek, Anton, Shariff, Faisal, Ploplis, Victoria, J. Castellino, Francis·2016·Current Drug Targets
DOI 10.2174/1389450117666160310153211PMC PMC5374842
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Abstract

Trauma-induced coagulopathy (TIC) is a recently described condition which traditionally has been diagnosed by the common coagulation tests (CCTs) such as prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), platelet count, and fibrinogen levels. The varying sensitivity and specificity of these CCTs have led trauma coagulation researchers and clinicians to use Viscoelastic Tests (VET) such as Thromboelastography (TEG) to provide Targeted Thromboelastographic Hemostatic and Adjunctive Therapy (TTHAT) in a goal directed fashion to those trauma patients in need of hemostatic resuscitation. This review describes the utility of VETs, in particular, TEG, to provide TTHAT in trauma and acquired non-trauma-induced coagulopathy. Keywords: Thromboelastography, point-of-care, acquired coagulopathy, blood component therapy, systemic hemostatic agents, trauma-induced coagulopathy, hemostatic resuscitation, tranexamic acid, targeted pharmacologic therapy.

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Crossref · 10.2174/1389450117666160310153211

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Figures

Fig. (1) Schematic of TEG with 0.36 mL aliquot of whole blood in cup with pin attached to torsion wire measuring pin synchronization with the cup, reflecting the stages of clot formation.
Fig. (1) Schematic of TEG with 0.36 mL aliquot of whole blood in cup with pin attached to torsion wire measuring pin synchronization with the cup, reflecting the stages of clot formation.CC BY-NC · PubMed Central
Fig. (2) Basic TEG/ROTEM parameters at 30 minutes after MA/MCF. TEG in black and ROTEM in red.
Fig. (2) Basic TEG/ROTEM parameters at 30 minutes after MA/MCF. TEG in black and ROTEM in red.CC BY-NC · PubMed Central
Fig. (3) Cup 1 is a standard-kaolin TEG that represents baseline clotting. Heparin is added to cups 2-4 in order to neutralize thrombin, while factor XIIIa and reptilase stimulate isolated fibrinogen formation so that the ADP and AA receptors in cups 3 and 4 platelet can be activated by ADP and AA respectively to create an isolated fibrinogen-platelet clot.
Fig. (3) Cup 1 is a standard-kaolin TEG that represents baseline clotting. Heparin is added to cups 2-4 in order to neutralize thrombin, while factor XIIIa and reptilase stimulate isolated fibrinogen formation so that the ADP and AA receptors in cups 3 and 4 platelet can be activated by ADP and AA respectively to create an isolated fibrinogen-platelet clot.CC BY-NC · PubMed Central
Fig. (4) The standard-kaolin TEG provides the baseline maximum amplitude (MA) which is compared to the MA of a second cup that contains abciximab. This results in the assessment of clot strength under platelet inhibition, which is represented by the green MA.
Fig. (4) The standard-kaolin TEG provides the baseline maximum amplitude (MA) which is compared to the MA of a second cup that contains abciximab. This results in the assessment of clot strength under platelet inhibition, which is represented by the green MA.CC BY-NC · PubMed Central
Fig. (5) Normal TEG tracing (in black) resembles a wide flat (non-functional) shovel with a short handle. The superimposed “shovel” (in red) demonstrates a tracing with a prolonged R, flat α-angle, small MA and increased LY30%, indicative of a systemic coagulopathy with fibrinolysis. *Some recommend LY30% >3% as threshold for anti-fibrinolytic agent [19,74].
Fig. (5) Normal TEG tracing (in black) resembles a wide flat (non-functional) shovel with a short handle. The superimposed “shovel” (in red) demonstrates a tracing with a prolonged R, flat α-angle, small MA and increased LY30%, indicative of a systemic coagulopathy with fibrinolysis. *Some recommend LY30% >3% as threshold for anti-fibrinolytic agent [19,74].CC BY-NC · PubMed Central
Fig. (6) MTP TEG/PM-guided BCT Algorithm. TEG/PM is performed upon arrival and every 30-45 minutes thereafter depending on severity of shock. Note: Where available order fibrinogen concentrate, PCC and rarely rFVIIA.. *Some algorithms recommend TXA for LY30 > 7.5% [48]. †Time to “anatomic hemostasis” was 100 minutes according to the PROPPR trial. [86, 122, 169]. ‡ With central venous access foundation ratio of 6PRBC, 3FFP, 1 SDAP, 10 U Cryoprecipitate given in first 20 minutes with subsequent ratios determined by clinical, laboratory and TEG/PM parameters.
Fig. (6) MTP TEG/PM-guided BCT Algorithm. TEG/PM is performed upon arrival and every 30-45 minutes thereafter depending on severity of shock. Note: Where available order fibrinogen concentrate, PCC and rarely rFVIIA.. *Some algorithms recommend TXA for LY30 > 7.5% [48]. †Time to “anatomic hemostasis” was 100 minutes according to the PROPPR trial. [86, 122, 169]. ‡ With central venous access foundation ratio of 6PRBC, 3FFP, 1 SDAP, 10 U Cryoprecipitate given in first 20 minutes with subsequent ratios determined by clinical, laboratory and TEG/PM parameters.CC BY-NC · PubMed Central

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Citations

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Research works printed but not linked: 2

  1. [62]Walsh M. Jbara M. Miller A. Lawson J. Thromboelastographic guided blood component therapy for severe hemorrhage. 2014 Blood Bulletin
  2. [77]Schochl H. Maegele M. Solomon C. Gorlinger K. Voelckel W. Early and individualized goal-directed therapy for trauma-induced coagulopathy. Scand. J. Trauma Resusc. Emerg. Med. 2012 20 15 1 11 22364525 PMC3306198

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Metadata

Authors
Walsh, M., Fritz, S., Hake, D., Son, M., Greve, S., Jbara, M., Chitta, S., Fritz, B., Miller, A., K Bader, M., McCollester, J., Binz, S., Liew-Spilger, A., Thomas, S., Crepinsek, A., Shariff, F., Ploplis, V., & J. Castellino, F.
Affiliations
  • Memorial Hospital of South Bend (US)
  • Indiana University South Bend (US)
  • Self Regional Healthcare (US)
  • Mayo Clinic (US)
  • University of Notre Dame (US)
Corresponding author
Walsh, Mark
ORCID
Venue
Current Drug Targets
Publisher
Bentham Science Publishers Ltd.
Published
2016-05-04
Volume
17
Issue
8
Pages
954-970
ISSN
1389-4501 (ISSN-L)
DOI
10.2174/1389450117666160310153211
PMC
PMC5374842
OpenAlex
W2295828145
Cited by
58
References
227
Citations by year
2026: 5 · 2025: 4 · 2024: 2 · 2023: 9 · 2022: 9 · 2021: 5 · 2020: 10 · 2019: 8 · 2018: 4 · 2017: 1 · 2016: 1
FWCI
0.73
Type
journal article
Language
en
Open access
Locations
  • Current Drug Targets (publishedVersion)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Digital Commons - East Tennessee State University (East Tennessee State University) (submittedVersion)
Funders
  • CSL Behring
  • Haemonetics Corporation
Topics
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Trauma, Hemostasis, Coagulopathy, Resuscitation
  • Health Sciences › Medicine › Hematology › Blood transfusion and management
  • Health Sciences › Medicine › Hematology › Hemostasis and retained surgical items
Keywords
trauma-induced coagulopathy, thromboelastography, viscoelastic coagulation tests, blood component therapy, hemostatic resuscitation, acquired coagulopathy, tranexamic acid, point-of-care coagulation testing, coagulation tests
MeSH terms
Blood Coagulation Disorders, Hemostatic Techniques, Humans, Partial Thromboplastin Time, Platelet Count, Prothrombin Time, Sensitivity and Specificity, Thrombelastography, Wounds and Injuries

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