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Review
. 2016;17(8):954-70.
doi: 10.2174/1389450117666160310153211.

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

Mark Walsh  1 , Stephanie Fritz, Daniel Hake, Michael Son, Sarah Greve, Manar Jbara, Swetha Chitta, Braxton Fritz, Adam Miller, Mary K Bader, Jonathon McCollester, Sophia Binz, Alyson Liew-Spilger, Scott Thomas, Anton Crepinsek, Faisal Shariff, Victoria Ploplis, Francis J Castellino
Affiliations
Review

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

Mark Walsh et al. Curr Drug Targets. 2016.

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.

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Figures

Fig. (1)
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. (2)
Fig. (2)
Basic TEG/ROTEM parameters at 30 minutes after MA/MCF. TEG in black and ROTEM in red.
Fig. (3)
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. (4)
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. (5)
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. (6)
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.
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