Activated clotting time of thrombelastography (T-ACT) predicts early postinjury blood component transfusion beyond plasma

Apolipoprotein A-I, elevated in trauma patients, inhibits platelet activation and decreases clot strength

Apolipoprotein A-I (ApoA-I) is elevated in the plasma of a subgroup of trauma patients with systemic hyperfibrinolysis. We hypothesize that apoA-I inhibits platelet activation and clot formation. The effects of apoA-I on human platelet activation and clot formation were assessed by whole blood thrombelastography (TEG), platelet aggregometry, P-selectin surface expression, microfluidic adhesion, and Akt phosphorylation. Mouse models of carotid artery thrombosis and pulmonary embolism were used to assess the effects of apoA-I in vivo. The ApoA-1 receptor was investigated with transgenic mice knockouts (KO) for the scavenger receptor class B member 1 (SR-BI). Compared to controls, exogenous human apoA-I inhibited arachidonic acid and collagen-mediated human and mouse platelet aggregation, decreased P-selectin surface expression and Akt activation, resulting in diminished clot strength and increased clot lysis by TEG. ApoA-I also decreased platelet aggregate size formed on a collagen surface under flow. In vivo, apoA-I delayed vessel occlusion in an arterial thrombosis model and conferred a survival advantage in a pulmonary embolism model. SR-BI KO mice significantly reduced apoA-I inhibition of platelet aggregation versus wild-type platelets. Exogenous human apoA-I inhibits platelet activation, decreases clot strength and stability, and protects mice from arterial and venous thrombosis via the SR-BI receptor.

Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center

Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy-especially in austere or challenging environments-is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.

The α-globin chain of hemoglobin potentiates tissue plasminogen activator induced hyperfibrinolysis in vitro

BACKGROUND

Severe injury predisposes patients to trauma-induced coagulopathy, which may be subdivided by the state of fibrinolysis. Systemic hyperfibrinolysis (HF) occurs in approximately 25% of these patients with mortality as high as 70%. Severe injury also causes the release of numerous intracellular proteins, which may affect coagulation, one of which is hemoglobin, and hemoglobin substitutes induce HF in vitro. We hypothesize that the α-globin chain of hemoglobin potentiates HF in vitro by augmenting plasmin activity.

METHODS

Proteomic analysis was completed on a pilot study of 30 injured patients before blood component resuscitation, stratified by their state of fibrinolysis, plus 10 healthy controls. Different concentrations of intact hemoglobin A, the α- and β-globin chains, or normal saline (controls) were added to whole blood, and tissue plasminogen activator (tPA)-challenged thrombelastography was used to assess the degree of fibrinolysis. Interactions with plasminogen (PLG) were evaluated using surface plasmon resonance. Tissue plasminogen activator-induced plasmin activity was evaluated in the presence of the α-globin chain.

RESULTS

Only the α- and β-globin chains increased in HF patients (p < 0.01). The α-globin chain but not hemoglobin A or the β-globin chain decreased the reaction time and significantly increased lysis time 30 on citrated native thrombelastographies (p < 0.05). The PLG and α-globin chain had interaction kinetics similar to tPA:PLG, and the α-globin chain increased tPA-induced plasmin activity.

CONCLUSIONS

The α-globin chain caused HF in vitro by binding to PLG and augmenting plasmin activity and may represent a circulating "moonlighting" mediator released by the tissue damage and hemorrhagic shock inherent to severe injury.

LEVEL OF EVIDENCE

Prognostic, level III.

Viscoelastic monitoring in trauma resuscitation

BACKGROUND

Traumatic injury results in both physical and physiologic insult. Successful care of the trauma patient depends upon timely correction of both physical and biochemical injury. Trauma-induced coagulopathy is a derangement of hemostasis and thrombosis that develops rapidly and can be fatal if not corrected. Viscoelastic monitoring (VEM) assays have been developed to provide rapid, accurate, and relatively comprehensive depictions of an individual's coagulation profile. VEM are increasingly being integrated into trauma resuscitation guidelines to provide dynamic and individualized guidance to correct coagulopathy.

STUDY DESIGN AND METHODS

We performed a narrative review of the search terms viscoelastic, thromboelastography, thromboelastometry, TEG, ROTEM, trauma, injury, resuscitation, and coagulopathy using PubMed. Particular focus was directed to articles describing algorithms for management of traumatic coagulopathy based on VEM assay parameters.

RESULTS

Our search identified 16 papers with VEM-guided resuscitation strategies in adult patients based on TEG, 12 such protocols in adults based on ROTEM, 1 protocol for children based on TEG, and 2 protocols for children based on ROTEM.

CONCLUSIONS

This review presents evidence to support VEM use to detect traumatic coagulopathy, discusses the role of VEM in trauma resuscitation, provides a summary of proposed treatment algorithms, and discusses pending questions in the field.

Circulating Syndecan-1 and Tissue Factor Pathway Inhibitor, Biomarkers of Endothelial Dysfunction, Predict Mortality in Burn Patients

OBJECTIVE

The aim of this study is to evaluate the association between burn injury and admission plasma levels of Syndecan-1 (SDC-1) and Tissue Factor Pathway Inhibitor (TFPI), and their ability to predict 30-day mortality.

BACKGROUND

SDC-1 and TFPI are expressed by vascular endothelium and shed into the plasma as biomarkers of endothelial damage. Admission plasma biomarker levels have been associated with morbidity and mortality in trauma patients, but this has not been well characterized in burn patients.Methods: This cohort study enrolled burn patients admitted to a regional burn center between 2013 and 2017. Blood samples were collected within 4 h of admission and plasma SDC-1 and TFPI were quantified by ELISA. Demographics and injury characteristics were collected prospectively. The primary outcome was 30-day in-hospital mortality.

RESULTS

Of 158 patients, 74 met inclusion criteria. Most patients were male with median age of 41.5 years and burn TBSA of 20.5%. The overall mortality rate was 20.3%. Admission SDC-1 and TFPI were significantly higher among deceased patients. Plasma SDC-1 >34 ng/mL was associated with a 32-times higher likelihood of mortality [OR: 32.65 (95% CI, 2.67-399.78); P = 0.006] and a strong predictor of mortality (area under the ROC [AUROC] 0.92). TFPI was associated with a nine-times higher likelihood of mortality [OR: 9.59 (95% CI, 1.02-89.75); P = 0.002] and a fair predictor of mortality (AUROC 0.68).

CONCLUSIONS

SDC-1 and TFPI are associated with a higher risk of 30-day mortality. We propose the measurement of SDC-1 on admission to identify burn patients at high risk of mortality. However, further investigation with a larger sample size is warranted.

The Current Role of Platelet Function Testing in Clinical Practice

Platelet dysfunction, whether hereditary or acquired, may increase an individual's risk of spontaneous, posttraumatic, or postoperative bleeding. Conversely, increased platelet reactivity on antiplatelet agents following vascular (in particular, coronary vascular) intervention may increase the risk of thrombosis and adverse vascular events. The aim of platelet function testing is to identify and characterize platelet dysfunction in these settings to inform bleeding/ thrombosis risk and guide perioperative prophylactic management strategies. A vast array of screening and diagnostic tests is available for this purpose. The successful clinical application of platelet function tests depends on the knowledge of their analytical strengths and limitations and the correct extrapolation of derived results to a particular clinical scenario. This review critically appraises traditional and contemporary platelet function testing focusing on their role in clinical practice.

Assessment of Coagulation Homeostasis in Blunt, Penetrating, and Thermal Trauma: Guidance for a Multicenter Systems Biology Approach

INTRODUCTION

Provisioning care for traumatically injured patients makes conducting research very proximal to injury difficult. These studies also inherently have regulatory barriers to overcome. Here we outline a protocol for acute-phase enrollment of traumatically injured patients into a prospective observational clinical trial with precise and comprehensive sample acquisition in support of a systems biology approach to a research study.

METHODS

Experts in trauma, burn, blood coagulation, computational biology, and integrative systems biology developed a prospective study that would capture the natural history of coagulation pathology after traumatic injury. Blood was sampled at admission and serial time points throughout hospitalization. Concurrently, demographic and outcomes data were recorded and on-site point-of-care testing was implemented. Protocols were harmonized across sites and sampling protocols validated through demonstration of feasibility and sample quality assurance testing. A novel data integration platform was developed to store, visualize, and enable large-scale analysis of empirical and clinical data. Regulatory considerations were also addressed in protocol development.

RESULTS

A comprehensive Manual of Operations (MOO) was developed and implemented at 3 clinical sites. After regulatory approval, the MOO was followed to collect 5,348 longitudinal samples from 1,547 patients. All samples were collected, processed, and stored per the MOO. Assay results and clinical data were entered into the novel data management platform for analyses.

CONCLUSION

We used an iterative, interdisciplinary process to develop a systematic and robust protocol for comprehensive assessment of coagulation in traumatically injured patients. This MOO can be a template for future studies in the acute setting.

Thromboelastography on-the-go: Evaluation of the TEG 6s device during ground and high-altitude Aeromedical Evacuation with extracorporeal life support

BACKGROUND

Coagulation monitoring capabilities during transport are limited. Thromboelastography (TEG) is a whole-blood clotting test measuring clot formation, stabilization, and fibrinolysis and is traditionally performed in a laboratory. We evaluated a new point-of-care TEG analyzer, TEG 6s (Haemonetics, Braintree, MA), in a large animal model of combat-relevant trauma managed with extracorporeal life support during ground and high-altitude aeromedical evacuation. The objective was to compare TEG 6s used during transport versus the predicate device, TEG 5000, used in the laboratory. We hypothesized that TEG 6s would be comparable with TEG 5000 during dynamically changing transport conditions.

METHODS

Thromboelastography parameters (R, K, angle, MA, LY30) derived by TEG 6s and TEG 5000 were compared during transport of 8 swine. TEG 6s was transported with animals during ground transport and flight. TEG 5000 was stationary in an adjacent building. TEG 6s activated clotting time (ACT) was compared with a Hemochron Junior ACT analyzer (Accriva Diagnostics, San Diego, CA). Statistics were performed using SAS 9.4 with Deming regressions, Spearman correlations, and average differences compared.

RESULTS

Correlation between devices was stronger at sea-level (R, r = 0.7413; K, r = 0.7115; angle, r = 0.7192; MA, r = 0.8386; LY30, r = 0.9099) than during high-altitude transport (R, r = 0.4787; K, r = 0.4007; angle, r = 0.3706; MA, r = 0.6573; LY30, r = 0.8481). Method agreement was comparable during stationary operation (R, r = 0.7978; K, r = 0.7974; angle, r = 0.7574; MA, r = 0.7841; LY30, r = 0.9140) versus ground transport (R, r = 0.7927; K, r = 0.6246; angle, r = 0.6967; MA, r = 0.9163; LY30, r = 0.8603). TEG 6s ACT trended higher than Hemochron ACT when subjects were heparinized (average difference, 1,442 ± 1,703 seconds) without a methodological difference by Deming regression.

CONCLUSION

Mobile TEG 6s during ground and altitude transport is feasible and provides unprecedented information to guide coagulation management. Future studies should assess the precision and accuracy of TEG 6s during transport of critically ill.

Viscoelastic Monitoring to Guide the Correction of Perioperative Coagulopathy and Massive Transfusion in Patients with Life-Threatening Hemorrhage

The resuscitation of patients with traumatic hemorrhage remains a challenging clinical scenario. The appropriate and aggressive support of the patient's coagulation is of critical importance. Conventional coagulation assays present several shortcomings in this setting. The integration of viscoelastic monitoring in clinical practice has the potential to result in significant improvements. In order to be successful, the provider must understand basics of the methodology, read outs, and the limitations of the technique.

Rapid TEG efficiently guides hemostatic resuscitation in trauma patients

BACKGROUND

Several thrombelastography functional assays have been developed to guide transfusion in injured patients, but how this acceleration of thrombelastography affects its ability to predict massive transfusion is unknown. The objective of this study is to compare citrated native, citrated kaolin, and citrated rapid thromboelastographies for their prediction of massive transfusion after trauma. We hypothesized that citrated native thrombelastography best predicts massive transfusion.

METHODS

Data were collected as part of a prospective study of trauma activation patients. All patients received citrated native, citrated kaolin, or citrated rapid thromboelastographies. Logistic regression was used to assess the predictive performance of different thrombelastography assays for massive transfusion.

RESULTS

Measurements for all three TEG activating systems was available for 343 patients; 57 (16.6%) required a massive transfusion. Compared to citrated rapid thromboelastographies, citrated kaolin thromboelastographies performed better for activated clotting time/rapid and citrated native thromboelastographies for maximum amplitude and angle. Yet, the 95% confidence intervals overlapped considerably, suggesting the citrated rapid thromboelastographies produced comparable results to the other assays for activated clotting time/reaction time, maximum amplitude, and angle.

CONCLUSION

There was substantial overlap in the performance of the different thrombelastography assays, suggesting citrated rapid thrombelastography is a quick and effective method to guide hemostatic resuscitation in trauma patients and does not perform inferiorly to the citrated native or citrated kaolin thrombelastography despite the addition of activation factors.

Preoperative thrombelastography maximum amplitude predicts massive transfusion in liver transplantation

BACKGROUND

Massive transfusion (MT) is frequently required during liver transplantation. Risk stratification of transplant patients at risk for MT is an appealing concept but remains poorly developed. Thrombelastography (TEG) has recently been shown to reduce mortality when used for trauma resuscitation. We hypothesize that preoperative TEG can be used to risk stratify patients for MT.

MATERIAL AND METHODS

Liver transplant patients had blood drawn before surgical incision and assayed via TEG. Preoperative TEG measurements were collected in addition to standard laboratory coagulation tests. TEG variables including R-time (reaction time), angle, maximum amplitude (MA), and LY30 (clot lysis 30 min after MA) were correlated to red blood cell units, plasma (fresh frozen plasma), cryoprecipitate, and platelets during the first 24 h after surgery and tested for their performance using a receiver-operating characteristic curve.

RESULTS

Twenty-eight patients were included in the analysis with a median Model for End-Stage Liver Disease score of 17; 36% received a MT. The TEG variables associated with MT (defined as ≥10 red blood cell units/24 h) were a low MA (P < 0.001) and low angle (P = 0.014). A high international normalized ratio of prothrombin time (P = 0.003) and low platelet count (P = 0.007) were also associated with MT. MA had the highest area under the curve (0.861) followed by international normalized ratio of prothrombin time (0.803). An MA of less than 47 mm has a sensitivity of 90% and specificity of 72% to predict a MT. MA was the only coagulation variable that correlated strongly to all blood products transfused.

CONCLUSIONS

TEG MA has a high predictability of MT during liver transplantation. The use of TEG preoperatively may help guide more cost effective blood bank preparation for this procedure as only a third of patients required a MT.

Rapid thrombelastography thresholds for goal-directed resuscitation of patients at risk for massive transfusion

BACKGROUND

Uncontrolled hemorrhage is a leading cause of mortality after trauma accounting for up to 40% of deaths. Massive transfusion protocols offer a proven benefit in resuscitation of these patients. Recently, the superiority of thrombelastography (TEG)-guided resuscitation over strategies guided by conventional clotting assays has been established. We seek to determine optimal thresholds for rapid (r)-TEG driven resuscitation.

METHODS

The r-TEG data were reviewed for 190 patients presenting to our level 1 trauma center from 2010 to 2015. Criteria for inclusion were highest level trauma activation in patients 18 years or older with hypotension presumed due to acute blood loss. Exclusion criteria included isolated gunshot wound to the head, pregnancy, and chronic liver disease. Receiver operating characteristic (ROC) analysis was performed to test the predictive performance of r-TEG for massive transfusion requirement defined by need for (1) >10 units of RBCs total or death in the first 6 hours or (2) >4 units of RBCs in any hour within the first 6 hours. Cutpoint analysis was then performed to determine optimal thresholds for TEG-based resuscitation.

RESULTS

The ROC analysis of r-TEG yielded areas under the curve (AUC) greater than 70% for all outputs with respect to both transfusion thresholds considered, with exception of activated clotting time and lysis at 30 minutes for greater than 4 U RBC in any hour in the first 6 hours. Optimal cutpoint analysis of the resultant ROC curves was performed and for each value, the most sensitive cutpoint was identified, respectively activated clotting time of 128 seconds or longer, angle (α) of 65 degrees or less, maximum amplitude of 55 mm or less, and lysis at 30 minutes of 5% or greater.

CONCLUSIONS

Through ROC analysis of prospective TEG data, we have identified optimal thresholds to guide hemostatic resuscitation. These thresholds should be validated in a prospective multicenter trial.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays

BACKGROUND

Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA).

METHODS

This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation. Upon MTP activation, patients were randomized to be managed either by an MTP goal directed by TEG or by CCA (ie, international normalized ratio, fibrinogen, platelet count). Primary outcome was 28-day survival.

RESULTS

One hundred eleven patients were included in an intent-to-treat analysis (TEG = 56, CCA = 55). Survival in the TEG group was significantly higher than the CCA group (log-rank P = 0.032, Wilcoxon P = 0.027); 20 deaths in the CCA group (36.4%) compared with 11 in the TEG group (19.6%) (P = 0.049). Most deaths occurred within the first 6 hours from arrival (21.8% CCA group vs 7.1% TEG group) (P = 0.032). CCA patients required similar number of red blood cell units as the TEG patients [CCA: 5.0 (2-11), TEG: 4.5 (2-8)] (P = 0.317), but more plasma units [CCA: 2.0 (0-4), TEG: 0.0 (0-3)] (P = 0.022), and more platelets units [CCA: 0.0 (0-1), TEG: 0.0 (0-0)] (P = 0.041) in the first 2 hours of resuscitation.

CONCLUSIONS

Utilization of a goal-directed, TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation.

Viscoelastic Tissue Plasminogen Activator Challenge Predicts Massive Transfusion in 15 Minutes

BACKGROUND

Coagulopathy is associated with massive transfusion in trauma, yet most clinical scores to predict this end point do not incorporate coagulation assays. Previous work has identified that shock increases circulating tissue plasminogen activator (tPA). When tPA levels saturate endogenous inhibitors, systemic hyperfibrinolysis can occur. Therefore, the addition of tPA to a patient's blood sample could stratify a patients underlying degree of shock and early coagulation changes to predict progression to massive transfusion. We hypothesized that a modified thrombelastography (TEG) assay with exogenous tPA would unmask patients' impending risk for massive transfusion.

STUDY DESIGN

Trauma activations were analyzed using rapid TEG and a modified TEG assay with a low and high dose of tPA. Clinical scores (shock index, assessment of blood consumption, and trauma-associated severe hemorrhage) were compared with TEG measurements to predict the need for massive transfusion using areas under the receiver operating characteristic curves.

RESULTS

Three hundred and twenty-four patients were analyzed, 17% required massive transfusion. Massive transfusion patients had a median shock index of 1.2, assessment of blood consumption score of 1, and trauma-associated severe hemorrhage score of 12. Rapid TEG and tPA TEG parameters were significantly different in all massive transfusion patients compared with non-massive transfusion patients (all p < 0.02). The low-dose tPA lysis at 30 minutes had the largest the area under the receiver operating characteristic curve (0.86; 95% CI 0.79 to 0.93) for prediction of massive transfusion, similar to international normalized ratio of prothrombin time of 0.86 (95% CI 0.81 to 0.91), followed by trauma-associated severe hemorrhage score (0.83; 95% CI 0.77 to 0.89). Combing trauma-associated severe hemorrhage and tPA-TEG variables results in a positive prediction of massive transfusion in 49% of patients with a 98% negative predictive value.

CONCLUSIONS

The tPA-TEG identifies trauma patients who require massive transfusion efficiently in a single assay that can be completed in a shorter time than other scoring systems, which has improved performance when combined with international normalized ratio. This new method is consistent with our understanding of the molecular events responsible for trauma-induced coagulopathy.

Management of Trauma-Induced Coagulopathy with Thrombelastography

Viscoelastic assays, such as thrombelastography (TEG) and rotational thrombelastometry (ROTEM), have emerged as point-of-care tools that can guide the hemostatic resuscitation of bleeding injured patients. This article describes the role of TEG in contemporary trauma care by explaining this assay's methodology, clinical applications, and result interpretation through description of supporting studies to provide the reader with an evidence-based user's guide. Although TEG and ROTEM are assays based on the same viscoelastic principle, this article is focused on data supporting the use of TEG in trauma, because it is available in trauma centers in North America; ROTEM is mostly available in Europe.

Prediction of Massive Transfusion in Trauma

Hemorrhage is the leading cause of preventable death in trauma. Damage control resuscitation relies on permissive hypotension, minimizing crystalloid use, and early implementation of massive transfusion protocols with established blood component ratios. These protocols improve the survival of the severely injured patient. Trauma physicians must quickly and accurately predict when a massive transfusion protocol should be activated. Several validated transfusion scores have been developed for this purpose. Many of these scores are useful for resuscitation research. One option, the ABC score, is an accurate, validated, and clinically useful score that is simple to calculate and rapidly obtained.

Thromboelastography in Orthopaedic Trauma Acute Pelvic Fracture Resuscitation: A Descriptive Pilot Study

OBJECTIVES

To describe the adjunctive use of thromboelastography (TEG) in directing initial blood component therapy resuscitation of patients with polytrauma with acute pelvic/acetabular fractures.

DESIGN

Retrospective cohort review.

SETTING

Level-2 trauma center.

PATIENTS

Forty adult trauma activations with acute pelvic and/or acetabular fractures were treated with standard fracture care and TEG with adjuvant platelet mapping (TEG/PM) analysis to guide their initial 24-hour resuscitation.

INTERVENTION

TEG with PM provided goal-directed hemostatic resuscitation using component blood products and an established hospital transfusion protocol. Transfusions were triggered by abnormal TEG/PM results and/or the presence of active hemorrhage, persistent hemorrhagic shock, and abnormal base deficit levels.

MAIN OUTCOME MEASUREMENT

The correction of trauma-induced coagulopathy was determined by the return of a normal TEG/PM tracing. The numbers of component blood products transfused in the first 24 hours using TEG/PM were calculated. Subgroup analysis of transfusion requirements and differences between pelvic ring and acetabular fracture patterns were determined.

RESULTS

More than 90% of patients received a transfusion of at least 1 blood product with 84% of transfusions occurring within 6 hours of admission. TEG/PM-guided resuscitation yielded greater volumes of platelets and packed red blood cells (PRBCs) versus fresh frozen plasma (FFP) (P = 0.018) with an average transfusion ratio of 2.5:1:2.8 (PRBC:FFP:platelet). There was a trend toward greater transfusion requirements in combined injuries versus pelvic ring or acetabular fractures (P = 0.08).

CONCLUSION

TEG with PM is a valuable adjunct to guide the acute phase of resuscitation in patients with polytrauma with pelvic injuries because it allows a real-time assessment of the coagulation status. The routine use of TEG/PM may result in transfusion ratios of blood products different from those of the current empiric 1:1:1 guidelines.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Massive hemorrhage management-a best evidence topic report

Introduction

Massive hemorrhage remains a major cause of potentially preventable deaths. Better control of bleeding could improve survival rates by 10%–20%. Transfusion intervention concepts have been formulated in order to minimize acute traumatic coagulopathy. These interventions still have not been standardized and vary among medical centers.

Materials and Methods

Based on a literature search using free term keywords and Medical Subject Heading (MeSH) index, we analyzed published articles addressing massive hemorrhage, component therapy, fresh whole blood, and fibrinogen from the year 2000 onward, in journals with impact factor >1.000, in Medline, PubMed, and Google Scholar. The evidence was grouped into topics including laboratory testing and transfusion interventions/viscoelastic assays vs standard laboratory tests, the effect of component therapy on patient outcome, the effect of warm fresh whole blood on patient outcome, and the effects of fibrinogen in severe bleeding. The obtained information was compared, evaluated, confronted, and was focused on to present an adequate and individual-based massive hemorrhage management approach.

Results

Viscoelastic whole-blood assays are superior to standard coagulation blood tests for the identification of coagulopathy and for guiding decisions on appropriate therapy in patients with severe bleeding. Replacement of plasma, red blood cells, platelets, and fibrinogen in a ratio of 1:1:1:1 has appeared to be the best substitution for lost whole blood. There is no evidence that cryoprecipitate improves the outcome of patients with severe hemorrhage. Current literature promotes the transfusion of warm fresh whole blood, which seems to be superior to the component therapy in certain clinical situations. Some authors recommend that fibrinogen and other coagulation factors be administered according to the viscoelastic attributes of the blood clot.

Conclusion

This best-evidence topic report brings comprehensive information about massive hemorrhage management.

TACTIC: Trans-Agency Consortium for Trauma-Induced Coagulopathy

Trauma-induced coagulopathy (TIC) includes heterogeneous coagulopathic syndromes with different underlying causes, and treatment is challenged by limited diagnostic tests to discriminate between these entities in the acute setting. We provide an overview of progress in understanding the mechanisms of TIC and the context for several of the hypotheses that will be tested in 'TACTIC'. Although connected to ongoing clinical trials in trauma, TACTIC itself has no intent to conduct clinical trials. We do anticipate that 'early translation' of promising results will occur. Functions anticipated at this early translational level include: (i) basic science groundwork for future therapeutic candidates; (ii) development of acute coagulopathy scoring systems; (iii) coagulation factor composition-based computational analysis; (iv) characterization of novel analytes including tissue factor, polyphosphates, histones, meizothrombin and α-thrombin-antithrombin complexes, factor XIa, platelet and endothelial markers of activation, signatures of protein C activation and fibrinolysis markers; and (v) assessment of viscoelastic tests and new point-of-care methods.