The “Death Diamond”

Abstract

Background Post-injury hyperfibrinolysis (HF), defined as LY30 ≥3% on rapid thrombelastography (rTEG), is associated with high mortality and large utilization of blood products. We observed that some cases of HF are reversible and are associated with patients who respond to hemostatic resuscitation; whereas, other cases of severe HF appear to be associated with these patients’ inevitable demise. We therefore sought to define this unsurvivable subtype of hyperfibrinolysis as a recognizable rTEG tracing pattern. Methods We queried our trauma registry for patients who either died or spent at least one day in the ICU, received at least one unit of PRBCs, and had an admission rTEG. Within this group of 572 patients, we identified 42 pairs of non-survivors and survivors who matched on age, sex, injury mechanism and NISS. We inspected the rTEG tracings to ascertain if any pattern was found exclusively within the non-surviving group and applied these findings to the cohort of 572 patients to assess the predictive value for mortality. Results Within the matched group 17% of patients developed HF. Within the HF subgroup, a unique rTEG pattern was present in 14 HF patients who died and in none of the survivors. This pattern was a “diamond-shaped” tracing with a short time to maximum amplitude (TMA) of ≤14 min and complete lysis before the LY30 point. Applying these criteria to the 572 unmatched patients, this pattern had a 100% positive predictive value for mortality. Conclusions Patients displaying the “black diamond” pattern on their admission rTEG are at higher risk for mortality. Given the volume of blood products and other resources that these patients consume, this TEG pattern may represent an objective criterion to discontinue efforts at hemostatic resuscitation.

Redefining postinjury fibrinolysis phenotypes using two viscoelastic assays

“…In contrast, LY30 used by rTEG occurs 30 minutes after maximum amplitude and gives the percentage decrease in amplitude at 30 minutes after MA. 18 Previous studies have shown that the median time to MA using rapid TEG is approximately 22 minutes, 19 with LY30 resulting 30 minutes from this time point. The median CT in our study was 67 seconds, with CLI60 occurring 60 minutes after this point.…”

Optimizing transfusion strategies in damage control resuscitation: current insights

“… 80 Within minutes of arrival, an unsurvivable subtype of primary HF can be recognized on r-TEG tracing as a characteristic diamond-shaped pattern. 81 Intravascular coagulation in concert with either primary or secondary HF consumes endogenous inhibitors leading to further coagulofibrinolytic dysregulation, a defining characteristic of DIC. DIC results in consumption of platelets and coagulation factors, 82 notably fibrinogen, which manifests clinically in the trauma patient as coagulopathy.…”

“…Neither HF nor fibrinolysis shutdown necessarily correlates with ISS or the magnitude of shock, although the development of either one of these two hemostatic abnormalities is associated with increasing mortality. Unregulated release of tPA from activated endothelial cells is suggested as the cause of HF, 81 , 90 – 92 whereas massive release of PAI-1 from activated platelets 93 may be the pathological basis of fibrinolysis shutdown. Also, impaired tPA generation due to SHINE is suggested as a contributing mechanism to fibrinolytic shutdown.…”

Viscoelastic testing inside and beyond the operating room

“…Trauma patients are at high risk of hemorrhage-related morbidity and mortality, and trauma-induced coagulopathy (TIC) further increases the risk of complications, need for transfusion, and length of stay (24). Previous studies in the trauma patient population have demonstrated hypocoagulability on viscoelastic tests to predict the need for massive transfusion (25)(26)(27)(28), the need for transfusion in general (29), and coagulopathy-related mortality (27,30).…”