Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care

Abstract

Uncontrolled bleeding is the leading cause of preventable death following injury. Trauma-induced coagulopathy can manifest as diverse phenotypes ranging from hypocoagulability to hypercoagulability, which can change quickly during the acute phase of trauma care. The major advances in understanding coagulation over the past 25 years have resulted from the cell-based concept, emphasizing the key role of platelets and their interaction with the damaged endothelium. Consequently, conventional plasma-based coagulation testing is not accurate in predicting bleeding and does not provide an assessment of which blood products are indicated. Viscoelastic hemostatic assays (VHA), conducted in whole blood, have emerged as a superior method to guide goal-directed transfusion. The major change in resuscitation has been the shift from unbridled crystalloid loading to judicious balanced blood product administration. Furthermore, the recognition of the rapid changes from hypocoagulability to hypercoagulability has underscored the importance of ongoing surveillance beyond emergent surgery. While the benefits of VHA testing are maximized when used as early as possible, current technology limits use in the pre-hospital setting and the time to results compromises its utility in the emergency department. Thus, most of the reported experience with VHA in trauma is in the operating room and intensive care unit, where there is compelling data to support its value. This overview will address the current and potential role of VHA in the seriously injured patient, throughout the continuum of trauma management.

Missingness matters: a secondary analysis of thromboelastography measurements from a recent prehospital randomized tranexamic acid clinical trial

“…The STAAMP Trial assessed 30-day mortality in 903 patients who were randomized to prehospital TXA (n=447) or placebo (n=456). This cohort was moderately injured with a median (IQR) ISS of 12 (5,22) and 30-day mortality of 9.0%. There were no significant differences in TEG parameters between patients that received TXA and those that received placebo in the overall study cohort.…”

“…The subset of YES-TEG patients (n=837) was similar to those patients included in the primary STAAMP Trial analysis regarding injury severity and demographics. In the YES-TEG cohort patients were predominantly male (75%) patients with median ages of 38 (26, 55) years who sustained blunt injuries (84%) with a median ISS of 12 (5,22). This subgroup of patients had a 30-day mortality rate of 6.8%, which was lower than that of the overall STAAMP Trial cohort.…”

“…Resuscitation after severe traumatic injury has transformed during the past decade, with the use of early blood products and adjunctive strategies to prevent coagulopathy, improve hemostasis and modulate the downstream immune response that complicates traumatic injury. [1][2][3][4][5] Concomitantly, there has been an increasing number of randomized clinical trials characterizing early resuscitation adjuncts to reduce coagulopathy and mortality attributable to traumatic injury. [6][7][8][9] Tranexamic acid (TXA) improves survival in patients with traumatic injury 7 9-12 and is hypothesized to mitigate hyperfibrinolysis and the ensuing coagulopathy induced by shock and traumatic hemorrhage.…”

Emerging Use of Viscoelastography in Thrombosis and Hemostasis: A Challenge to Conventional Coagulation Tests? Part I: The Use of Thromboelastography and Thromboelastometry in the Assessment of Hemostatic Function

“…Viscoelastographic measures can be done at point of care with rapid turnaround time. Such advantage is fully utilized in the management of trauma patients, as discussed previously by Moore and colleagues, and in the current issue by Meizoso et al 4,5 Another potential application of this methodology is in the monitoring of anticoagulant therapy. 6 This is especially useful in patients with marked variation in the coagulation status such as in complicated cases in the emergency department.…”

Mechanism matters: mortality and endothelial cell damage marker differences between blunt and penetrating traumatic injuries across three prehospital clinical trials

“…The management of severe traumatic injury has undergone significant evolution over the past decade, with a focus on prevention of coagulopathy, early blood transfusion and modulation of the downstream immune response which complicates traumatic injury [1][2][3][4][5] . Concomitantly, there has been an increasing number of randomized clinical trials characterizing early interventions to reduce the morbidity and mortality attributable to hemorrhage and severe injury [6][7][8][9] .…”