Skip to main content
SpringerLink
Log in

Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays?

  • Hemostasis after Trauma (N Saillant, Section Editor)
  • Published:
Current Trauma Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management to include indications for use across all phases of care in the injured patient.

Recent Findings

Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings.

Summary

Both hypocoagulable and hypercoagulable states exist in trauma patients, and viscoelastic assays are better at diagnosing both relative to standard coagulation testing and can better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Centers for Disease Control NCfIPaC. Web-based Injury Statistics Query and Reporting System (WISQARS) [online] Accessed February 14, 2017. [Available from: https://www.cdc.gov/injury/wisqars/leadingcauses.html.

  2. Sobrino J, Shafi S. Timing and causes of death after injuries. Proc (Bayl Univ Med Cent). 2013;26(2):120–3.

    Google Scholar 

  3. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38(2):185–93.

    CAS  PubMed  Google Scholar 

  4. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3–11.

    PubMed  Google Scholar 

  5. Maegele M, Paffrath T, Bouillon B. Acute traumatic coagulopathy in severe injury: incidence, risk stratification, and treatment options. Dtsch Arztebl Int. 2011;108(49):827–35.

    PubMed  PubMed Central  Google Scholar 

  6. Gonzalez E, Moore EE, Moore HB. Management of trauma-induced coagulopathy with thrombelastography. Crit Care Clin. 2017;33(1):119–34.

    PubMed  PubMed Central  Google Scholar 

  7. •• Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2016;263(6):1051–9 This manuscript reports outcomes from a randomized controlled trial of trauma patients undergoing massive transfusion, demonstrating a 50% reduction in 28-day mortality using thromboelastography to guide massive transfusion in bleeding trauma patients relative to conventional coagulation assays (INR, platelet count, fibrinogen level).

    PubMed  Google Scholar 

  8. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127–30.

    PubMed  Google Scholar 

  9. • Moore HB, Moore EE, Liras IN, Gonzalez E, Harvin JA, Holcomb JB, et al. Acute fibrinolysis shutdown after injury occurs frequently and increases mortality: a multicenter evaluation of 2,540 severely injured patients. J Am Coll Surg. 2016;222(4):347–55 This was a large retrospective study of trauma patients that confirmed and clearly defined the U-shaped mortality curve associated with the spectrum of fibrinolysis (patho)phenotypes previously described an earlier and smaller report by the same authors’, demonstrating an increased risk of death when trauma patients had too little fibrinolysis (fibrinolysis shutdown) or too much fibrinolysis (hyperfibrinolysis). This work has formed the basis for many of the current arguments behind selective use of TXA in trauma patients.

    PubMed  PubMed Central  Google Scholar 

  10. Moore HB, Moore EE, Gonzalez E, Chapman MP, Chin TL, Silliman CC, et al. Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance to antifibrinolytic therapy. J Trauma Acute Care Surg. 2014;77(6):811–7 discussion 7.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular trauma--a unified approach. J Trauma. 1982;22(8):672–9.

    CAS  PubMed  Google Scholar 

  12. Schreiber MA. Coagulopathy in the trauma patient. Curr Opin Crit Care. 2005;11(6):590–7.

    PubMed  Google Scholar 

  13. Gando S, Nanzaki S, Morimoto Y, Kobayashi S, Kemmotsu O. Systemic activation of tissue-factor dependent coagulation pathway in evolving acute respiratory distress syndrome in patients with trauma and sepsis. J Trauma. 1999;47(4):719–23.

    CAS  PubMed  Google Scholar 

  14. Park MS, Martini WZ, Dubick MA, Salinas J, Butenas S, Kheirabadi BS, et al. Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time. J Trauma. 2009;67(2):266–75 discussion 75-6.

    PubMed  PubMed Central  Google Scholar 

  15. Kaufmann CR, Dwyer KM, Crews JD, Dols SJ, Trask AL. Usefulness of thrombelastography in assessment of trauma patient coagulation. J Trauma. 1997;42(4):716–20 discussion 20-2.

    CAS  PubMed  Google Scholar 

  16. Chapman MP, Moore EE, Moore HB, Gonzalez E, Gamboni F, Chandler JG, et al. Overwhelming tPA release, not PAI-1 degradation, is responsible for hyperfibrinolysis in severely injured trauma patients. J Trauma Acute Care Surg. 2016;80(1):16–23 discussion −5.

    CAS  PubMed  PubMed Central  Google Scholar 

  17. Cardenas JC, Matijevic N, Baer LA, Holcomb JB, Cotton BA, Wade CE. Elevated tissue plasminogen activator and reduced plasminogen activator inhibitor promote hyperfibrinolysis in trauma patients. Shock. 2014;41(6):514–21.

    CAS  PubMed  Google Scholar 

  18. Moore EE, Moore HB, Gonzalez E, Chapman MP, Hansen KC, Sauaia A, et al. Postinjury fibrinolysis shutdown: rationale for selective tranexamic acid. J Trauma Acute Care Surg. 2015;78(6 Suppl 1):S65–9.

    PubMed  PubMed Central  Google Scholar 

  19. Moore HB, Moore EE, Chapman MP, Hansen KC, Cohen MJ, Pieracci FM, et al. Does tranexamic acid improve clot strength in severely injured patients who have elevated fibrin degradation products and low fibrinolytic activity, measured by thrombelastography? J Am Coll Surg. 2019;229(1):92–101.

    PubMed  PubMed Central  Google Scholar 

  20. McCully BH, Connelly CR, Fair KA, Holcomb JB, Fox EE, Wade CE, et al. Onset of coagulation function recovery is delayed in severely injured trauma patients with venous thromboembolism. J Am Coll Surg. 2017;225(1):42–51.

    PubMed  PubMed Central  Google Scholar 

  21. Byrne JP, Mason SA, Gomez D, Hoeft C, Subacius H, Xiong W, et al. Timing of pharmacologic venous thromboembolism prophylaxis in severe traumatic brain injury: a propensity-matched cohort study. J Am Coll Surg. 2016;223(4):621–31 e5.

    PubMed  Google Scholar 

  22. Joseph B, Pandit V, Harrison C, Lubin D, Kulvatunyou N, Zangbar B, et al. Early thromboembolic prophylaxis in patients with blunt solid abdominal organ injuries undergoing nonoperative management: is it safe? Am J Surg. 2015;209(1):194–8.

    PubMed  Google Scholar 

  23. Rostas JW, Manley J, Gonzalez RP, Brevard SB, Ahmed N, Frotan MA, et al. The safety of low molecular-weight heparin after blunt liver and spleen injuries. Am J Surg. 2015;210(1):31–4.

    PubMed  Google Scholar 

  24. Murphy PB, Sothilingam N, Charyk Stewart T, Batey B, Moffat B, Gray DK, et al. Very early initiation of chemical venous thromboembolism prophylaxis after blunt solid organ injury is safe. Can J Surg. 2016;59(2):118–22.

    PubMed  PubMed Central  Google Scholar 

  25. Asakura H, Ontachi Y, Mizutani T, Kato M, Saito M, Kumabashiri I, et al. An enhanced fibrinolysis prevents the development of multiple organ failure in disseminated intravascular coagulation in spite of much activation of blood coagulation. Crit Care Med. 2001;29(6):1164–8.

    CAS  PubMed  Google Scholar 

  26. Hardaway RM, Harke H, Tyroch AH, Williams CH, Vazquez Y, Krause GF. Treatment of severe acute respiratory distress syndrome: a final report on a phase I study. Am Surg. 2001;67(4):377–82.

    CAS  PubMed  Google Scholar 

  27. Tanaka T, Tsujinaka T, Kambayashi J, Higashiyama M, Yokota M, Sakon M, et al. The effect of heparin on multiple organ failure and disseminated intravascular coagulation in a sepsis model. Thromb Res. 1990;60(4):321–30.

    CAS  PubMed  Google Scholar 

  28. Richey SL. Tourniquets for the control of traumatic hemorrhage: a review of the literature. World J Emerg Surg. 2007;2:28.

    PubMed  PubMed Central  Google Scholar 

  29. Smith ER, Shapiro GL. Totally tourniquets. The facts & details about different types of tourniquets. JEMS. 2013;38(11):48 50, 2.

    PubMed  Google Scholar 

  30. King DR, van der Wilden G, Kragh JF Jr, Blackbourne LH. Forward assessment of 79 prehospital battlefield tourniquets used in the current war. J Spec Oper Med. 2012;12(4):33–8.

    PubMed  Google Scholar 

  31. Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting. Emerg Med J. 2007;24(8):584–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. Ribeiro Junior MAF, Feng CYD, Nguyen ATM, Rodrigues VC, Bechara GEK, de-Moura RR, et al. The complications associated with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). World J Emerg Surg. 2018;13:20.

    PubMed  PubMed Central  Google Scholar 

  33. •• Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, et al. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med. 2018;379(4):315–26 This was a 501 patient randomized controlled trial evaluating the use of fresh frozen plasma (FFP) versus standard crystalloid-based resuscitation during air medical transport of trauma patients at high risk for ongoing hemorrhage. The authors found significantly reduced 30-day mortality in the group treated with FFP, and importantly, a survival difference was noted as early as 3 h after randomization. The FFP group also had lower INR values upon arrival to the trauma center. This study population had notably longer pre-hospital transport times (median 39 min) relative to the COMBAT study (less than 20 min), which did not find a survival benefit from FFP when compared to standard crystalloid-based resuscitation.

    PubMed  Google Scholar 

  34. collaborators C-t, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23–32.

    Google Scholar 

  35. Beekley AC. Damage control resuscitation: a sensible approach to the exsanguinating surgical patient. Crit Care Med. 2008;36(7 Suppl):S267–74.

    PubMed  Google Scholar 

  36. Lewin I, Weil MH, Shubin H, Sherwin R. Pulmonary failure associated with clinical shock states. J Trauma. 1971;11(1):22–35.

    CAS  PubMed  Google Scholar 

  37. • EMH G, Moore EE, editors. Trauma induced coagulopathy. New York: Springer Scientific; 2016. This is the first textbook dedicated to comprehensively reviewing trauma induced coagulopathy as well as the underlying principles behind hemostasis, coagulation, and fibrinolysis in trauma. This text includes expansive sections explaining the TEG and ROTEM mechanisms as well as interpretation of the output variables.

    Google Scholar 

  38. Ball CG. Damage control resuscitation: history, theory and technique. Can J Surg. 2014;57(1):55–60.

    PubMed  PubMed Central  Google Scholar 

  39. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the randomized clinical trial. JAMA. 2015;313(5):471–82.

    CAS  PubMed  PubMed Central  Google Scholar 

  40. Sheppard FR, Schaub LJ, Cap AP, Macko AR, Moore HB, Moore EE, et al. Whole blood mitigates the acute coagulopathy of trauma and avoids the coagulopathy of crystalloid resuscitation. J Trauma Acute Care Surg. 2018;85(6):1055–62.

    PubMed  Google Scholar 

  41. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55(1):39–44.

    PubMed  Google Scholar 

  42. Cannon WBFJ, Cowell E. The preventive treatment of wound shock. JAMA. 1918;70:618–21.

    Google Scholar 

  43. Moore HB, Moore EE, Liras IN, Wade C, Huebner BR, Burlew CC, et al. Targeting resuscitation to normalization of coagulating status: hyper and hypocoagulability after severe injury are both associated with increased mortality. Am J Surg. 2017;214(6):1041–5.

    PubMed  PubMed Central  Google Scholar 

  44. Knudson MM, Ikossi DG, Khaw L, Morabito D, Speetzen LS. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg. 2004;240(3):490–6 discussion 6–8.

    PubMed  PubMed Central  Google Scholar 

  45. Martini WZ. Coagulation complications following trauma. Mil Med Res. 2016;3:35.

    PubMed  PubMed Central  Google Scholar 

  46. O’Malley KF, Ross SE. Pulmonary embolism in major trauma patients. J Trauma. 1990;30(6):748–50.

    PubMed  Google Scholar 

  47. Subramanian M, Kaplan LJ, Cannon JW. Thromboelastography-guided resuscitation of the trauma patient. JAMA Surg. 2019.

  48. Gale AJ. Continuing education course #2: current understanding of hemostasis. Toxicol Pathol. 2011;39(1):273–80.

    PubMed  Google Scholar 

  49. Eisenberg JM, Clarke JR, Sussman SA. Prothrombin and partial thromboplastin times as preoperative screening tests. Arch Surg. 1982;117(1):48–51.

    CAS  PubMed  Google Scholar 

  50. Hartert H., Klin Wochenschr. 1948;26(37–38):577–583 [Not Available].

    CAS  PubMed  Google Scholar 

  51. De Nicola P, Mazzetti GM. Evaluation of thrombelastography. Am J Clin Pathol. 1955;23(4):447–52.

    Google Scholar 

  52. Von Kaulla KN, Weiner M. Studies of coagulation and fibrinolysis by new technic of continuous recording. Blood. 1955;10(4):362–9.

    Google Scholar 

  53. Sankarankutty A, Nascimento B, Teodoro da Luz L, Rizoli S. TEG(R) and ROTEM(R) in trauma: similar test but different results? World J Emerg Surg. 2012;7(Suppl 1):S3.

    PubMed  PubMed Central  Google Scholar 

  54. Harr JN, Moore EE, Ghasabyan A, Chin TL, Sauaia A, Banerjee A, et al. Functional fibrinogen assay indicates that fibrinogen is critical in correcting abnormal clot strength following trauma. Shock. 2013;39(1):45–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  55. Dias JD, Haney EI, Mathew BA, Lopez-Espina CG, Orr AW, Popovsky MA. New-generation thromboelastography: comprehensive evaluation of citrated and heparinized blood sample storage effect on clot-forming variables. Arch Pathol Lab Med. 2017;141(4):569–77.

    PubMed  Google Scholar 

  56. Meledeo MA, Peltier GC, McIntosh CS, Voelker CR, Bynum JA, Cap AP. Functional stability of the TEG 6 s hemostasis analyzer under stress. J Trauma Acute Care Surg. 2018;84(6S Suppl 1):S83–S8.

    CAS  PubMed  Google Scholar 

  57. •• Einersen PM, Moore EE, Chapman MP, Moore HB, Gonzalez E, Silliman CC, et al. Rapid thrombelastography thresholds for goal-directed resuscitation of patients at risk for massive transfusion. J Trauma Acute Care Surg. 2017;82(1):114–9 R-TEG® data was analyzed from 190 trauma patients to determine the predictive power of ACT, angle, MA, and LY30 in relation to outcomes including whether massive transfusion was required, 24-h mortality, ICU-, and ventilator-free days. ROC curves were generated and guided the authors to suggest the values at which the different R-TEG® variables reasonably suggested the need for massive transfusion as well as R-TEG® variable cutoffs for individual component transfusions. Of the R-TEG® variables, angle and MA were found to be the strongest predictors of requiring massive transfusion (AUROC ≥ 80%).

    PubMed  PubMed Central  Google Scholar 

  58. Tapia NM, Chang A, Norman M, Welsh F, Scott B, Wall MJ Jr, et al. TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients. J Trauma Acute Care Surg. 2013;74(2):378–85 discussion 85–6.

    CAS  PubMed  Google Scholar 

  59. Fahrendorff M, Oliveri RS, Johansson PI. The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products - a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2017;25(1):39.

    PubMed  PubMed Central  Google Scholar 

  60. Mohamed M, Majeske K, Sachwani GR, Kennedy K, Salib M, McCann M. The impact of early thromboelastography directed therapy in trauma resuscitation. Scand J Trauma Resusc Emerg Med. 2017;25(1):99.

    PubMed  PubMed Central  Google Scholar 

  61. Yeung MC, Tong SY, Tong PY, Cheung BH, Ng JY, Leung GK. Use of viscoelastic haemostatic assay in emergency and elective surgery. Hong Kong Med J. 2015;21(1):45–51.

    PubMed  Google Scholar 

  62. Moore HB, Moore EE, Chapman MP, McVaney K, Bryskiewicz G, Blechar R, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomized trial. Lancet. 2018;392(10144):283–91.

    PubMed  PubMed Central  Google Scholar 

  63. Schroll R, Swift D, Tatum D, Couch S, Heaney JB, Llado-Farrulla M, et al. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury. 2018;49(1):15–9.

    PubMed  Google Scholar 

  64. Zhu CS, Cobb D, Jonas RB, Pokorny D, Rani M, Cotner-Pouncy T, et al. Shock index and pulse pressure as triggers for massive transfusion. J Trauma Acute Care Surg. 2019.

  65. Schreiber MA, Perkins J, Kiraly L, Underwood S, Wade C, Holcomb JB. Early predictors of massive transfusion in combat casualties. J Am Coll Surg. 2007;205(4):541–5.

    PubMed  Google Scholar 

  66. Rozycki GS, Ochsner MG, Schmidt JA, Frankel HL, Davis TP, Wang D, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. 1995;39(3):492–8 discussion 8–500.

    CAS  PubMed  Google Scholar 

  67. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998;228(4):557–67.

    CAS  PubMed  PubMed Central  Google Scholar 

  68. McLaughlin DF, Niles SE, Salinas J, Perkins JG, Cox ED, Wade CE, et al. A predictive model for massive transfusion in combat casualty patients. J Trauma. 2008;64(2 Suppl):S57–63 discussion S.

    PubMed  Google Scholar 

  69. Callcut RA, Johannigman JA, Kadon KS, Hanseman DJ, Robinson BR. All massive transfusion criteria are not created equal: defining the predictive value of individual transfusion triggers to better determine who benefits from blood. J Trauma. 2011;70(4):794–801.

    PubMed  Google Scholar 

  70. Zhang J, Jiang R, Liu L, Watkins T, Zhang F, Dong JF. Traumatic brain injury-associated coagulopathy. J Neurotrauma. 2012;29(19):2597–605.

    PubMed  PubMed Central  Google Scholar 

  71. Maegele M. Coagulopathy after traumatic brain injury: incidence, pathogenesis, and treatment options. Transfusion. 2013;53(Suppl 1):28S–37S.

    PubMed  Google Scholar 

  72. Laroche M, Kutcher ME, Huang MC, Cohen MJ, Manley GT. Coagulopathy after traumatic brain injury. Neurosurgery. 2012;70(6):1334–45.

    PubMed  Google Scholar 

  73. Gennarelli TA, Champion HR, Copes WS, Sacco WJ. Comparison of mortality, morbidity, and severity of 59,713 head injured patients with 114,447 patients with extracranial injuries. J Trauma. 1994;37(6):962–8.

    CAS  PubMed  Google Scholar 

  74. McMahon CG, Yates DW, Campbell FM, Hollis S, Woodford M. Unexpected contribution of moderate traumatic brain injury to death after major trauma. J Trauma. 1999;47(5):891–5.

    CAS  PubMed  Google Scholar 

  75. van der Jagt M. Fluid management of the neurological patient: a concise review. Crit Care. 2016;20(1):126.

    PubMed  PubMed Central  Google Scholar 

  76. Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus. 2017;43(5):E9.

    PubMed  Google Scholar 

  77. Foreman PM, Harrigan MR. Blunt traumatic extracranial cerebrovascular injury and ischemic stroke. Cerebrovasc Dis Extra. 2017;7(1):72–83.

    PubMed  PubMed Central  Google Scholar 

  78. Shafafy R, Suresh S, Afolayan JO, Vaccaro AR, Panchmatia JR. Blunt vertebral vascular injury in trauma patients: ATLS((R)) recommendations and review of current evidence. J Spine Surg. 2017;3(2):217–25.

    PubMed  PubMed Central  Google Scholar 

  79. Dewan MC, Ravindra VM, Gannon S, Prather CT, Yang GL, Jordan LC, et al. Treatment practices and outcomes after blunt cerebrovascular injury in children. Neurosurgery. 2016;79(6):872–8.

    PubMed  Google Scholar 

  80. Brommeland T, Helseth E, Aarhus M, Moen KG, Dyrskog S, Bergholt B, et al. Best practice guidelines for blunt cerebrovascular injury (BCVI). Scand J Trauma Resusc Emerg Med. 2018;26(1):90.

    PubMed  PubMed Central  Google Scholar 

  81. Sumislawski JJ, Moore HB, Moore EE, Swope ML, Pieracci FM, Fox CJ, et al. Not all in your head (and neck): stroke after blunt cerebrovascular injury is associated with systemic hypercoagulability. J Trauma Acute Care Surg. 2019;87(5):1082–7.

    PubMed  Google Scholar 

  82. Asensio JA, Roldan G, Petrone P, Rojo E, Tillou A, Kuncir E, et al. Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps. J Trauma. 2003;54(4):647–53 discussion 53–4.

    PubMed  Google Scholar 

  83. Doklestic K, Stefanovic B, Gregoric P, Ivancevic N, Loncar Z, Jovanovic B, et al. Surgical management of AAST grades III-V hepatic trauma by damage control surgery with perihepatic packing and definitive hepatic repair-single centre experience. World J Emerg Surg. 2015;10:34.

    PubMed  PubMed Central  Google Scholar 

  84. Palta S, Saroa R, Palta A. Overview of the coagulation system. Indian J Anaesth. 2014;58(5):515–23.

    CAS  PubMed  PubMed Central  Google Scholar 

  85. Raum D, Marcus D, Alper CA, Levey R, Taylor PD, Starzl TE. Synthesis of human plasminogen by the liver. Science. 1980;208(4447):1036–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  86. Walker FJ. Protein C deficiency in liver disease. Ann Clin Lab Sci. 1990;20(2):106–12.

    CAS  PubMed  Google Scholar 

  87. Harrison MF. The misunderstood coagulopathy of liver disease: a review for the acute setting. West J Emerg Med. 2018;19(5):863–71.

    PubMed  PubMed Central  Google Scholar 

  88. Davis JPE, Northup PG, Caldwell SH, Intagliata NM. Viscoelastic testing in liver disease. Ann Hepatol. 2018;17(2):205–13.

    CAS  PubMed  Google Scholar 

  89. Georgiou C, Inaba K, Teixeira PG, Hadjizacharia P, Chan LS, Brown C, et al. Cirrhosis and trauma are a lethal combination. World J Surg. 2009;33(5):1087–92.

    PubMed  Google Scholar 

  90. Christmas AB, Wilson AK, Franklin GA, Miller FB, Richardson JD, Rodriguez JL. Cirrhosis and trauma: a deadly duo. Am Surg. 2005;71(14):996–1000.

    PubMed  Google Scholar 

  91. Demetriades D, Constantinou C, Salim A, Velmahos G, Rhee P, Chan L. Liver cirrhosis in patients undergoing laparotomy for trauma: effect on outcomes. J Am Coll Surg. 2004;199(4):538–42.

    PubMed  Google Scholar 

  92. Wahlstrom K, Ney AL, Jacobson S, Odland MD, Van Camp JM, Rodriguez JL, et al. Trauma in cirrhotics: survival and hospital sequelae in patients requiring abdominal exploration. Am Surg. 2000;66(13):1071–6.

    CAS  PubMed  Google Scholar 

  93. Boufous S, Finch C, Lord S, Close J. The increasing burden of pelvic fractures in older people, New South Wales. Australia Injury. 2005;36(13):1323–9.

    PubMed  Google Scholar 

  94. Cryer HM, Miller FB, Evers BM, Rouben LR, Seligson DL. Pelvic fracture classification: correlation with hemorrhage. J Trauma. 1988;28(7):973–80.

    CAS  PubMed  Google Scholar 

  95. Rothenberger D, Velasco R, Strate R, Fischer RP, Perry JF Jr. Open pelvic fracture: a lethal injury. J Trauma. 1978;18(3):184–7.

    CAS  PubMed  Google Scholar 

  96. Henry SM, Pollak AN, Jones AL, Boswell S, Scalea TM. Pelvic fracture in geriatric patients: a distinct clinical entity. J Trauma. 2002;53(1):15–20.

    PubMed  Google Scholar 

  97. Ben-Menachem Y, Coldwell DM, Young JW, Burgess AR. Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management. AJR Am J Roentgenol. 1991;157(5):1005–14.

    CAS  PubMed  Google Scholar 

  98. Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5.

    PubMed  PubMed Central  Google Scholar 

  99. Colson PH, Gaudard P, Fellahi JL, Bertet H, Faucanie M, Amour J, et al. Active bleeding after cardiac surgery: a prospective observational multicenter study. PLoS One. 2016;11(10):e0162396.

    PubMed  PubMed Central  Google Scholar 

  100. Shen L, Tabaie S, Ivascu N. Viscoelastic testing inside and beyond the operating room. J Thorac Dis. 2017;9(Suppl 4):S299–308.

    PubMed  PubMed Central  Google Scholar 

  101. Curry NS, Davenport R, Pavord S, Mallett SV, Kitchen D, Klein AA, et al. The use of viscoelastic haemostatic assays in the management of major bleeding: a British Society for Hematology Guideline. Br J Haematol. 2018;182(6):789–806.

    PubMed  Google Scholar 

  102. Erdoes G, Schloer H, Eberle B, Nagler M. Next generation viscoelasticity assays in cardiothoracic surgery: feasibility of the TEG6s system. PLoS One. 2018;13(14):e0209360.

    CAS  PubMed  PubMed Central  Google Scholar 

  103. Roullet S, de Maistre E, Ickx B, Blais N, Susen S, Faraoni D, et al. Position of the French Working Group on Perioperative Hemostasis (GIHP) on viscoelastic tests: what role for which indication in bleeding situations? Anaesth Crit Care Pain Med. 2019;38(5):539–48.

    PubMed  Google Scholar 

  104. Alamo JM, Leon A, Mellado P, Bernal C, Marin LM, Cepeda C, et al. Is “intra-operating room” thromboelastometry useful in liver transplantation? A case-control study in 303 patients. Transplant Proc. 2013;45(12):3637–9.

    PubMed  Google Scholar 

  105. Wang YX, Griffith JF, Deng M, Heather TM, Zhang YF, Yan SX, et al. Compromised perfusion in femoral head in normal rats: distinctive perfusion MRI evidence of contrast washout delay. Br J Radiol. 2012;85(1016):e436–41.

    PubMed  PubMed Central  Google Scholar 

  106. Leon-Justel A, Noval-Padillo JA, Alvarez-Rios AI, Mellado P, Gomez-Bravo MA, Alamo JM, et al. Point-of-care hemostasis monitoring during liver transplantation reduces transfusion requirements and improves patient outcome. Clin Chim Acta. 2015;446:277–83.

    CAS  PubMed  Google Scholar 

  107. Gurusamy KS, Pissanou T, Pikhart H, Vaughan J, Burroughs AK, Davidson BR. Methods to decrease blood loss and transfusion requirements for liver transplantation. Cochrane Database Syst Rev. 2011;(14):CD009052.

  108. McCrossin KE, Bramley DE, Hessian E, Hutcheon E, Imberger G. Viscoelastic testing for hepatic surgery: a systematic review with meta-analysis-a protocol. Syst Rev. 2016;5(1):151.

    PubMed  PubMed Central  Google Scholar 

  109. Spinella PC, Pidcoke HF, Strandenes G, Hervig T, Fisher A, Jenkins D, et al. Whole blood for hemostatic resuscitation of major bleeding. Transfusion. 2016;56(Suppl 2):S190–202.

    PubMed  Google Scholar 

  110. Spinella PC, Cap AP. Whole blood: back to the future. Curr Opin Hematol. 2016;23(6):536–42.

    PubMed  Google Scholar 

  111. Yazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock AD. Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. J Trauma Acute Care Surg. 2016;81(1):21–6.

    PubMed  Google Scholar 

  112. Neal MD, Moore HB, Moore EE, Freeman K, Cohen MJ, Sperry JL, et al. Clinical assessment of trauma-induced coagulopathy and its contribution to postinjury mortality: a TACTIC proposal. J Trauma Acute Care Surg. 2015;79(3):490–2.

    PubMed  PubMed Central  Google Scholar 

  113. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331(26):1601–6.

    CAS  PubMed  Google Scholar 

  114. Park MS, Perkins SE, Spears GM, Ashrani AA, Leibson CL, Boos CM, et al. Risk factors for venous thromboembolism after acute trauma: a population-based case-cohort study. Thromb Res. 2016;144:40–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  115. Frohlich M, Lefering R, Probst C, Paffrath T, Schneider MM, Maegele M, et al. Epidemiology and risk factors of multiple-organ failure after multiple trauma: an analysis of 31,154 patients from the Trauma Register DGU. J Trauma Acute Care Surg. 2014;76(4):921–7 discussion 7–8.

    PubMed  Google Scholar 

  116. Kuo SCH, Kuo PJ, Chen YC, Chien PC, Hsieh HY, Hsieh CH. Comparison of the new Exponential Injury Severity Score with the Injury Severity Score and the New Injury Severity Score in trauma patients: a cross-sectional study. PLoS One. 2017;12(13):e0187871.

    PubMed  PubMed Central  Google Scholar 

  117. Blasi A, Molina V, Sanchez-Cabus S, Balust J, Garcia-Valdecasas JC, Taura P. Prediction of thromboembolic complications after liver resection for cholangiocarcinoma: is there a place for thromboelastometry? Blood Coagul Fibrinolysis. 2018;29(1):61–6.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Chicago School of Medicine, Chicago, IL, USA

    Sanjeev Dhara

  2. Department of Surgery, University of Colorado Denver, Denver, CO, USA

    Ernest E. Moore & Hunter B. Moore

  3. Ernest E. Moore Shock and Trauma Center, Denver Health Medical Center, Denver, CO, USA

    Ernest E. Moore

  4. Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Michael B. Yaffe & Christopher D. Barrett

  5. Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA

    Michael B. Yaffe & Christopher D. Barrett

Authors
  1. Sanjeev Dhara
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ernest E. Moore
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael B. Yaffe
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hunter B. Moore
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christopher D. Barrett
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Hunter B. Moore or Christopher D. Barrett.

Ethics declarations

Conflict of Interest

Dr. H. Moore reports grants from the National Institutes of Health during the conduct of the study, another from Thrombo Therapeutics, Inc. outside the submitted work. In addition, Dr. Moore has a patent pending A Modified Coagulation Assay That Rapidly Unmasks Pathological Fibrinolysis Phenotypes in a Wide Spectrum of Human Diseases. In addition, Dr. Moore has a patent Fibrinolysis Detection issued.

Dr. Ernest Moore reports non-financial, research support from Haemonetics, non-financial support from Instrumentation Laboratory, and non-financial support from Stago outside the submitted work. In addition, Dr. E. Moore has a patent Fibrinolysis Detection issued and is Co-Founder of ThromboTherapeutics.

Dr. Barrett reports grants from National Institutes of Health during the conduct of the study and another from Thrombo Therapeutics, Inc. outside the submitted work. In addition, Dr. Barrett has a patent pending A Modified Coagulation Assay That Rapidly Unmasks Pathological Fibrinolysis Phenotypes in a Wide Spectrum of Human Diseases.

Dr. Yaffe reports grants from National Institutes of Health during the conduct of the study and another from Thrombo Therapeutics, Inc. outside the submitted work. In addition, Dr. Barrett has a patent pending A Modified Coagulation Assay That Rapidly Unmasks Pathological Fibrinolysis Phenotypes in a Wide Spectrum of Human Diseases.

Mr. Dhara has nothing to disclose.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors were performed in accordance with all applicable ethical standards including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Hemostasis after Trauma

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dhara, S., Moore, E.E., Yaffe, M.B. et al. Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays?. Curr Trauma Rep 6, 69–81 (2020). https://doi.org/10.1007/s40719-020-00183-w

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40719-020-00183-w

Keywords

Search

Navigation