A prospective evaluation of thromboelastometry (ROTEM) to identify acute traumatic coagulopathy and predict massive transfusion in military trauma patients in Afghanistan

Abstract

BACKGROUND Hemorrhage is the leading cause of preventable trauma‐related mortality and is frequently aggravated by acute traumatic coagulopathy (ATC). Viscoelastic tests such as rotational thromboelastometry (ROTEM) may improve identification and management of ATC. This study aimed to prospectively evaluate changes in ROTEM among combat casualties during the first 24 hours and compare the capabilities of our conventional clotting assay (international normalized ratio [INR], >1.2) to a proposed integrated ROTEM model (INR >1.2 with the addition of tissue factor pathway activation thromboelastometry [EXTEM] A5 ≤35 mm and/or EXTEM LI30 <97% on admission) to identify ATC and predict massive transfusion (MT). STUDY DESIGN AND METHODS This was a prospective observational study of trauma patients treated in NATO hospitals in Afghanistan between January 2012 and June 2013. ROTEM (EXTEM, functional fibrinogen thromboelastometry, APTEM, EXTEM with the addition of a fibrinolysis inhibitor) was performed on admission and at 6 and 24 hours by a designated research team. Treatment teams did not have access to the ROTEM results. RESULTS ROTEM values were available for 40 male casualties. The integrated ROTEM model classified 15% more patients with ATC than with INR alone and increased the detection of those that required MT by 22%. The sensitivity of the integrated ROTEM model to predict MT was higher than with INR greater than 1.2 (86% vs. 64%); however, specificity with both definitions for predicting MT was poor (38% vs. 50%, respectively). CONCLUSION These observations support the importance of early identification of and intervention in ATC. Integrating ROTEM into the definition of ATC would increase detection of those requiring MT arguing for its use as an adjunct to clinical presentation in the ultimate decision to initiate MT.

A prospective observational study of acute traumatic coagulopathy in traumatic bleeding from the battlefield

“…This study proposed that ROTEM was more sensitive when used as a hybrid score, rather than a single parameter. These findings are similar to Cohen et al, who described 40 combat casualties in Afghanistan. They considered an “integrated score” where patients had either an international normalized ratio (INR) greater than 1.2, or an A5 less than 35 mm or a Li30 less than 97%.…”

Patient Blood Management

“…39 Avoiding intraoperative coagulopathy is also important and its detection and treatment is greatly facilitated by monitoring via viscoelastic testing (thromboelastography, thromboelastometry) in combination with laboratory testing and a specific coagulation algorithm. [40][41][42][43][44] Ideally, this algorithm should focus on individualized goal-directed treatment of a specific defect detected with coagulation monitoring. [40][41][42][43][44] Since fibrinogen is a critical hemostatic protein, in bleeding patients the level should be maintained at greater than or equal to 1.5 g/l.…”

Medical Application of Hydrogen in Hematological Diseases

“…Severe hemorrhage is a major cause of death in trauma and accident. Lethal hemorrhage is also the leading cause of death in war injury [20, 21]. During uncontrolled hemorrhage, hemostasis and reinfusion by blood transfusion are always the most important.…”