Introduction Rapid thrombelastography (rTEG) has been advocated as a point-of-care test to manage trauma-induced coagulopathy. rTEG activated clotting time (T-ACT) results become available much sooner than other rTEG values, thus offering an attractive tool to guide blood component transfusion in a hemorrhagic shock. We hypothesize that patients with a prolonged T-ACT require replacement of platelets (Plts) and cryoprecipitate (Cryo) in addition to plasma to correct trauma-induced coagulopathy. Methods A prospective trauma registry was reviewed for patients with an r-TEG available within 3 hours of injury. Blood was collected via a standardized protocol for rTEG. Patients were stratified into quartiles: low (T-ACT <113 seconds), mild (T-ACT 113–120 seconds), moderate (T-ACT 121–140 seconds), and severe (T-ACT >140 seconds). Transfusion requirements were evaluated during the first 6 hours after injury. Results A total of 114 patients were included. Median age was 39 years, injury severity score 20, base-deficit 10, and mortality rate 13%. T-ACT cohorts had similar age (P = .11), injury severity score (P = .55), and base deficit (P = .38). An T-ACT >140 seconds predicted a lower angle (median 57 vs 70, P <.000) and maximum amplitude (46 vs 60, P = .002), and patients received more Cryo (0.5 vs 0, P ≤ .000) and Plts (1 vs 0, P = .006). Conclusion Injured patients requiring resuscitation with blood transfusion that have a T-ACT > 140 seconds are polycoagulopathic and may benefit from early Cryo and Plts.

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A British soldier presented to the UK Field Hospital, Afghanistan with bilateral traumatic lower limb amputations. Resuscitation and surgery followed accepted damage control principles. Blood component therapy was in keeping with UK military guidelines and included platelets and cryoprecipitate. The patient's trachea was extubated following insertion of an effective epidural. Ten days later, in the UK, he developed neurological symptoms and the presence of a subdural haematoma was confirmed on magnetic resonance imaging. Conventional laboratory coagulation results in this patient were above accepted limits for epidural insertion; however, thromboelastometry before insertion was suggestive of reduced platelet function. This case highlights the risk of relying solely on platelet count as a marker of platelet function following massive transfusion. Thromboelastometry provides additional information for the assessment of coagulation and should form part of the assessment of coagulation following massive transfusion before epidural insertion. The acceptable standards for coagulation tests and platelet count before epidural catheter insertion are well established [1,2]. We report a case of subdural haematoma occurring after catheter insertion in a patient with acceptable laboratory tests of coagulation but with near patient thromboelastometry (ROTEM; Pentpharm GMBH, Munich, Germany) suggestive of reduced platelet function. Case historyA male soldier presented to the Role 3 UK Military Hospital, Afghanistan with bilateral traumatic lower limb amputations secondary to blast from an improvised explosive device. Resuscitation and surgery followed damage control principles with volume resuscitation in accordance with UK military guidelines, as outlined by Kirkman et al. [3] in reviewing coagulopathy of trauma. The patient received 26 units of packed red cells, 25 units of fresh frozen plasma, three units of pooled platelets, three units of cryoprecipitate and 1 g tranexamic acid.The patient was admitted to the intensive care unit and remained sedated with controlled ventilation. Following an assessment of his haemodynamic stability, further management included planned extubation after establishing effective epidural analgesia.Initial epidural placement was unsuccessful using a 16-G Tuohy needle by means of a midline approach at the L3 ⁄ 4 interspace with the patient in the left lateral position; there was resistance to the feeding of the catheter on first pass and blood in the catheter on subsequent placement. Subsequently, a second operator successfully sited an epidural catheter, though once again there was resistance to threading the catheter at the L3 ⁄ 4 interspace. The catheter was sited uneventfully at the L2 ⁄ 3 interspace with the patient in the left lateral position using a 16-G Tuohy needle and a midline approach, with the establishment of an effective block.

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