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Three Part Question

In [trauma patients], is [thromboelastography (TEG) superior to conventional coagulation studies] in [guiding blood transfusion strategy]?

Clinical Scenario

A 34-year-old male is brought by EMS as a trauma activation s/p MVC. He was an unrestrained driver with +LOC. En route, vitals deteriorated to the following: 80/45, 125, 28, 96%. He was intubated for airway protection. On arrival to the ED, GCS is 3T. As 2L crystalloid are being infused through 2 large bore IVs, ETT is confirmed to be in place, breath sounds are CTAB, carotid and femoral pulses are 1+ and thready bilateral. On exam, he has a seatbelt sign and initial FAST is positive. Trauma blood transfusion is initiated. Initial labs are drawn in the ED and he is taken straight to the OR by trauma surgery. You know that TEG is useful in transplant and cardiac surgery and wonder if a TEG-directed transfusion strategy will improve this patient’s clinical outcome.

Search Strategy

PubMed search: (((thrombelastography[Title]) OR TEG[Title]) AND transfusion[Title/Abstract]) AND trauma[Title/Abstract]

Search Outcome

27 papers found, of which 22 were irrelevant or of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Holcomb et al 2012 USA	1974 consecutive adult patients admitted between September 2009 and February 2011 who met the highest-level trauma activation criteria. All had admission TEG and CCTs (PT, aPTT, INR, platelet count and fibrinogen)	Retrospective cohort study	Correlation of TEG to CCTs	Overall, TEG correlated with CCTs.	Retrospective design
			Volume of blood product transfusion	TEG values were superior to CCTs in predicting volume of blood product transfusion.
Tapia et al 2013 USA	289 trauma patients receiving at least 6 units of PRBCs in the first 24 hours of admission for 21 months before and after MTP initiation in an urban Level I trauma center. PreMTP (TEG-based): 165 patients; MTP: 124 patients	Retrospective Cohort	24-hour volume of blood product transfusion	No difference	Retrospective design
			30-day mortality	No difference overall. Subgroup analysis of penetrating trauma patients who received >10U PRBCs demonstrate an increased mortality (54.1%) with use of MTP as compared to TEG (33.3%)
Yin et al 2014 China	60 adult patients with abdominal trauma who received at least 2 units of PRBCs within 24 hours of admission (TEG-based: 29 patients; Control/ CCTs: 31 patients)	Retrospective Cohort	Volume of blood product administration	No statistically significant difference in volume of blood product transfusion at 24 hours. Subgroup analysis including patients with ISS ≥16 showed that patients in the TEG-directed group had significantly smaller volume of transfusion products than patients in the control group.	Small numbers; retrospective design
			Mortality	No difference
			ICU length of stay	No difference
			Hospital length of stay	No difference
Da Luz et al 2014 Canada	12,489 adult trauma patients assessed using TEG/ ROTEM. Fifty-five studies met inclusion criteria, including 38 prospective cohort studies, 15 retrospective cohort studies, two before-after studies, and no randomized trials.	Systematic Review	Ability to diagnose early trauma-induced coagulopathy; Mortality; Blood product transfusion	Limited evidence from observational data suggests that TEG/ROTEM tests diagnose early trauma coagulopathy and may predict blood-product transfusion and mortality in trauma.	Limited quality of included studies; No randomized trials
Hunt et al 2015 UK	430 adult patients with clinically suspected trauma-induced coagulopathy. Three cross- sectional studies were included from the UK, France and Afghanistan in both civilian and military trauma settings. All studies used ROTEM; none used TEG.	Systematic Review	Correlation of TEG and ROTEM with CCTs	No evidence was reported supporting the correlation of TEG with CCTs and very little evidence supports the correlation of ROTEM with CCTs.	Small number of studies included; No investigation of volume of transfusion products, mortality, or other end-points; no randomized trials

Comment(s)

Adequately powered and methodologically sound RCTs will be required to prove positive effects of TEG on blood-product transfusion and patient-important outcomes.

Editor Comment

Trauma

Clinical Bottom Line

Limited evidence from observational data suggests that TEG/ROTEM tests diagnose early trauma coagulopathy and may predict blood-product transfusion and mortality in trauma. The effects of TEG on blood-product transfusion, mortality, and other patient-important outcomes remain unproven in randomized trials.

References

1. Holcomb JB, Minei KM, Scerbo ML, Radwan ZA, Wade CE, Kozar RA, Gill BS, Albarado R, McNutt MK, Khan S, Adams PR, McCarthy JJ, Cotton BA Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients Ann Surg 2012 Sep; 256(3): 476-86
2. Tapia NM, Chang A, Norman M, Welsh F, Scott B, Wall MJ Jr, Mattox KL, Suliburk J TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients J Trauma Acute Care Surg 2013 Feb;74(2):378-86
3. Yin J, Zhao Z, Li Y, Wang J, Yao D, Zhang S, Yu W, Li N, Li J Goal-directed transfusion protocol via thrombelastography in patients with abdominal trauma: a retrospective study World J Emerg Surg 2014 Apr 15; 9:28
4. Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review Crit Care 2014 Sep 27;18(5):518
5. Hunt H, Stanworth S, Curry N, Woolley T, Cooper C, Ukoumunne O, Zhelev Z, Hyde C Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma-induced coagulopathy in adult trauma patients with bleeding Cochrane Database Syst Rev 2015 Feb 16