Laboratory Assessment of Coagulation

  • Hunter B. Moore
  • Eduardo Gonzalez
  • Ernest E. Moore


Trauma-induced coagulopathy (TIC) is a multifactorial process associated with increased mortality from hemorrhage, thrombotic complications, and organ failure. TIC represents a spectrum of hyper- and hypocoagulation, which is driven from systemic shock, tissue injury, and reperfusion. These coagulation abnormalities can be related to endothelium, platelets, coagulation factors, fibrinogen, red cells, and neutrophils. The complexity of these interacting systems explains why conventional plasma-based assays are suboptimal in treating coagulopathy following severe injury.

Viscoelastic assays have been used clinically to analyze coagulation abnormalities for over half a century, although interest in their implementation to guide trauma care was not popularized until recently. These assays yield comparable actionable results that would require five conventional coagulation assays and provide results in a clinically relevant time to provide goal-directed resuscitation. These assays also have predictive value for massive transfusion and mortality. Prospective data suggest that viscoelastic-based resuscitation in trauma patients undergoing massive transfusion can reduce mortality by 50%. While multicenter validation of these findings remains to be completed, the benefits of viscoelastic resuscitation are hard to ignore.

The appropriate infrastructure and supporting staff that can run, analyze, and act upon the results of these assays is essential. Implementation of goal-directed resuscitation will undoubtedly be fraught with logistical problems, as the appropriate implementation of massive transfusion protocol already exists as an international problem.


TEG ROTEM Viscoelastic assay Massive transfusion Goal-directed resuscitation Trauma Tic Coagulopathy 


  1. 1.
    Hoffman M, Monroe DM 3rd. A cell-based model of hemostasis. Thromb Haemost. 2001;85(6):958–65.CrossRefPubMedGoogle Scholar
  2. 2.
    Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127–30.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Peltan ID, Vande Vusse LK, Maier RV, Watkins TR. An international normalized ratio-based definition of acute traumatic coagulopathy is associated with mortality, venous thromboembolism, and multiple organ failure after injury. Crit Care Med. 2015;43(7):1429–38.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Cotton BA, Faz G, Hatch QM, Radwan ZA, Podbielski J, Wade C, et al. Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma. 2011;71(2):407–14; discussion 14-7.CrossRefPubMedGoogle Scholar
  5. 5.
    Vogel AM, Radwan ZA, Cox CS Jr, Cotton BA. Admission rapid thrombelastography delivers real-time “actionable” data in pediatric trauma. J Pediatr Surg. 2013;48(6):1371–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Moore HB, Moore EE, Chin TL, Gonzalez E, Chapman MP, Walker CB, et al. Activated clotting time of thrombelastography (T-ACT) predicts early postinjury blood component transfusion beyond plasma. Surgery. 2014;156(3):564–9.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Schochl H, Frietsch T, Pavelka M, Jambor C. Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma. 2009;67(1):125–31.CrossRefPubMedGoogle Scholar
  8. 8.
    Hoffman M, Colina CM, McDonald AG, Arepally GM, Pedersen L, Monroe DM. Tissue factor around dermal vessels has bound factor VII in the absence of injury. J Thromb Haemost JTH. 2007;5(7):1403–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Rao LV, Rapaport SI. Activation of factor VII bound to tissue factor: a key early step in the tissue factor pathway of blood coagulation. Proc Natl Acad Sci U S A. 1988;85(18):6687–91.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Tracy PB, Giles AR, Mann KG, Eide LL, Hoogendoorn H, Rivard GE, Factor V. (Quebec): a bleeding diathesis associated with a qualitative platelet factor V deficiency. J Clin Invest. 1984;74(4):1221–8.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Mazepa M, Hoffman M, Monroe D. Superactivated platelets: thrombus regulators, thrombin generators, and potential clinical targets. Arterioscler Thromb Vasc Biol. 2013;33(8):1747–52.CrossRefPubMedGoogle Scholar
  12. 12.
    Monroe DM, Roberts HR, Hoffman M. Platelet procoagulant complex assembly in a tissue factor-initiated system. Br J Haematol. 1994;88(2):364–71.CrossRefPubMedGoogle Scholar
  13. 13.
    Ostrowski SR, Johansson PI. Endothelial glycocalyx degradation induces endogenous heparinization in patients with severe injury and early traumatic coagulopathy. J Trauma Acute Care Surg. 2012;73(1):60–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Brohi K, Cohen MJ, Ganter MT, Matthay MA, Mackersie RC, Pittet JF. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg. 2007;245(5):812–8.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kashuk JL, Moore EE, Le T, Lawrence J, Pezold M, Johnson JL, et al. Noncitrated whole blood is optimal for evaluation of postinjury coagulopathy with point-of-care rapid thrombelastography. J Surg Res. 2009;156(1):133–8.CrossRefGoogle Scholar
  17. 17.
    Haas T, Spielmann N, Cushing M. Impact of incorrect filling of citrate blood sampling tubes on thromboelastometry. Scand J Clin Lab Invest. 2015;75(8):717–9.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Doering CJ, Wagg CR, Caulkett NA, McAllister RK, Brookfield CE, Paterson JM, et al. Comparison of arterial and venous whole blood clot initiation, formation, and strength by thromboelastography in anesthetized swine. Blood Coagul Fibrinolysis: Int J Haemost Thromb. 2014;25(1):20–4.CrossRefGoogle Scholar
  19. 19.
    Manspeizer HE, Imai M, Frumento RJ, Parides MK, Mets B, Bennett-Guerrero E. Arterial and venous Thrombelastograph variables differ during cardiac surgery. Anesth Analg. 2001;93(2):277–81. 1st contents page.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Neate SL, Boysen SR, Wagg CR, Radics SL, Caulkett NA. Comparison of thromboelastography parameters between different catheter lumen diameters in an uncontrolled haemorrhagic shock model in swine. Blood Coagul Fibrinolysis: Int J Haemost Thromb. 2013;24(6):581–6.CrossRefGoogle Scholar
  21. 21.
    Moore HB, Moore EE, Chapman MP, Gonzalez E, Slaughter AL, Morton AP, et al. Viscoelastic measurements of platelet function, not fibrinogen function, predicts sensitivity to tissue-type plasminogen activator in trauma patients. J Thromb Haemost JTH. 2015;13(10):1878–87.CrossRefPubMedGoogle Scholar
  22. 22.
    Schreiber MA, Differding J, Thorborg P, Mayberry JC, Mullins RJ. Hypercoagulability is most prevalent early after injury and in female patients. J Trauma. 2005;58(3):475–80; discussion 80-1.CrossRefPubMedGoogle Scholar
  23. 23.
    Schlimp CJ, Solomon C, Ranucci M, Hochleitner G, Redl H, Schochl H. The effectiveness of different functional fibrinogen polymerization assays in eliminating platelet contribution to clot strength in thromboelastometry. Anesth Analg. 2014;118(2):269–76.CrossRefPubMedGoogle Scholar
  24. 24.
    Chapman MP, Moore EE, Burneikis D, Moore HB, Gonzalez E, Anderson KC, et al. Thrombelastographic pattern recognition in renal disease and trauma. J Surg Res. 2015;194(1):1–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Holcomb JB, Minei KM, Scerbo ML, Radwan ZA, Wade CE, Kozar RA, et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients. Ann Surg. 2012;256(3):476–86.CrossRefPubMedGoogle Scholar
  26. 26.
    David JS, Durand M, Levrat A, Lefevre M, Rugeri L, Geay-Baillat MO, et al. Correlation between laboratory coagulation testing and thromboelastometry is modified during management of trauma patients. J Trauma Acute Care Surg. 2016;81(2):319–27.CrossRefPubMedGoogle Scholar
  27. 27.
    Schochl H, Schlimp CJ, Voelckel W. Potential value of pharmacological protocols in trauma. Curr Opin Anaesthesiol. 2013;26(2):221–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Woolley T, Midwinter M, Spencer P, Watts S, Doran C, Kirkman E. Utility of interim ROTEM((R)) values of clot strength, A5 and A10, in predicting final assessment of coagulation status in severely injured battle patients. Injury. 2013;44(5):593–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Meyer AS, Meyer MA, Sorensen AM, Rasmussen LS, Hansen MB, Holcomb JB, et al. Thrombelastography and rotational thromboelastometry early amplitudes in 182 trauma patients with clinical suspicion of severe injury. J Trauma Acute Care Surg. 2014;76(3):682–90.CrossRefPubMedGoogle Scholar
  30. 30.
    Kashuk JL, Moore EE, Pinski S, Johnson JL, Moore JB, Morgan S, et al. Lower extremity compartment syndrome in the acute care surgery paradigm: safety lessons learned. Patient Saf Surg. 2009;3(1):11.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Solomon C, Schochl H, Ranucci M, Schlimp CJ. Can the viscoelastic parameter alpha-angle distinguish fibrinogen from platelet deficiency and guide fibrinogen supplementation? Anesth Analg. 2015;121(2):289–301.CrossRefPubMedGoogle Scholar
  32. 32.
    Harr JN, Moore EE, Chin TL, Chapman MP, Ghasabyan A, Stringham JR, et al. Viscoelastic hemostatic fibrinogen assays detect fibrinolysis early. Eur J Trauma Emerg Surg. 2015;41(1):49–56.CrossRefPubMedGoogle Scholar
  33. 33.
    Tauber H, Innerhofer P, Breitkopf R, Westermann I, Beer R, El Attal R, et al. Prevalence and impact of abnormal ROTEM(R) assays in severe blunt trauma: results of the ‘Diagnosis and treatment of trauma-induced coagulopathy (DIA-TRE-TIC) study’. Br J Anaesth. 2011;107(3):378–87.CrossRefPubMedGoogle Scholar
  34. 34.
    Chapman MP, Moore EE, Ramos CR, Ghasabyan A, Harr JN, Chin TL, et al. Fibrinolysis greater than 3% is the critical value for initiation of antifibrinolytic therapy. J Trauma Acute Care Surg. 2013;75(6):961–7.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Cotton BA, Harvin JA, Kostousouv V, Minei KM, Radwan ZA, Schochl H, et al. Hyperfibrinolysis at admission is an uncommon but highly lethal event associated with shock and prehospital fluid administration. J Trauma Acute Care Surg. 2012;73(2):365–70; discussion 70.CrossRefPubMedGoogle Scholar
  36. 36.
    Harvin JA, Peirce CA, Mims MM, Hudson JA, Podbielski JM, Wade CE, et al. The impact of tranexamic acid on mortality in injured patients with hyperfibrinolysis. J Trauma Acute Care Surg. 2015;78(5):905–11.CrossRefPubMedGoogle Scholar
  37. 37.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Kutcher ME, Ferguson AR, Cohen MJ. A principal component analysis of coagulation after trauma. J Trauma Acute Care Surg. 2013;74(5):1223–9; discussion 9-30.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Chin TL, Moore EE, Moore HB, Gonzalez E, Chapman MP, Stringham JR, et al. A principal component analysis of postinjury viscoelastic assays: clotting factor depletion versus fibrinolysis. Surgery. 2014;156(3):570–7.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    White NJ, Contaifer D Jr, Martin EJ, Newton JC, Mohammed BM, Bostic JL, et al. Early hemostatic responses to trauma identified with hierarchical clustering analysis. J Thromb Haemost JTH. 2015;13(6):978–88.CrossRefPubMedGoogle Scholar
  41. 41.
    Morton AP, Moore EE, Wohlauer MV, Lo K, Silliman CC, Burlew CC, et al. Revisiting early postinjury mortality: are they bleeding because they are dying or dying because they are bleeding? J Surg Res. 2013;179(1):5–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805–13.CrossRefGoogle Scholar
  43. 43.
    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 PROPPR randomized clinical trial. JAMA. 2015;313(5):471–82.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    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.CrossRefPubMedGoogle Scholar
  45. 45.
    Hagemo JS, Naess PA, Johansson P, Windelov NA, Cohen MJ, Roislien J, et al. Evaluation of TEG((R)) and RoTEM((R)) inter-changeability in trauma patients. Injury. 2013;44(5):600–5.CrossRefPubMedGoogle Scholar
  46. 46.
    Etchill E, Sperry J, Zuckerbraun B, Alarcon L, Brown J, Schuster K, et al. The confusion continues: results from an American Association for the Surgery of Trauma survey on massive transfusion practices among United States trauma centers. Transfusion. 2016;56:2478–86.CrossRefPubMedGoogle Scholar
  47. 47.
    Schafer N, Driessen A, Frohlich M, Sturmer EK, Maegele M, Partners T. Diversity in clinical management and protocols for the treatment of major bleeding trauma patients across European level I Trauma Centres. Scand J Trauma Resusc Emerg Med. 2015;23:74.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Hunter B. Moore
    • 1
  • Eduardo Gonzalez
    • 1
  • Ernest E. Moore
    • 2
    • 3
  1. 1.Department of SurgeryUniversity of ColoradoDenverUSA
  2. 2.Department of Surgery, University of Colorado DenverDenverUSA
  3. 3.Department of Surgery, Denver HealthDenverUSA

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