USE OF ROTATIONAL THROMBOELASTOMETRY FOR OPTIMAL MANAGEMENT OF EARLY RESUSCITATION OF BLEEDING TRAUMA PATIENTS

Early trauma-induced coagulopathy (TIC) is associated with uncontrollable bleeding, high transfusion requirements and mortality. Current management strategies of coagulopathic bleeding trauma patients are either guided by untimely laboratory tests (goal-directed) or blind transfusion protocols according to pre-established formulas (damage-control, 1:1:1). Both strategies have significant limitations that may account for the poor outcome of many patients. Viscoelastometric tests such as rotational thromboelastometry (ROTEM) are emerging technologies with potential to revolutionize resuscitation of rapidly bleeding trauma patients. This project aims to investigate the role of ROTEM in early trauma resuscitation, including TIC diagnosis, guiding blood transfusion and predicting 24h mortality. The overarching hypothesis is that ROTEM parameters measured immediately upon hospital admission, may predict increased transfusion requirements, including massive transfusion (MT), and 24h mortality, and thus could guide blood and blood product transfusions. In order to explore this hypothesis, a series of approaches have been performed. A systematic review and international consensus conference with a panel of renowned experts in trauma, critical care, hematology, and surgery were done. They established the ROTEM parameters and values used for the diagnosis of TIC, guidance of blood transfusion and prediction of 24h mortality. Next, patient data from two major Canadian trauma centers were obtained to develop and validate prediction models for assessing the risk of requiring blood and blood product transfusion (red blood cells (RBC), plasma, cryoprecipitate and platelets), massive transfusion (MT) and 24h mortality using ROTEM and readily available clinical variables. The systematic review and the consensus conference indicated that low clot amplitude was associated with transfusion requirements, MT and 24h mortality but exact ROTEM parameters values could not be determined due to equipment limitations (i.e. high coefficient of variability) and poor understanding of their physiologic meaning (i.e. meaning of hyper coagulability parameters). Similarly, patient data analysis demonstrated that low clot amplitude, both in extrinsic (EXTEM) and fibrinogen pathways (FIBTEM), along with clinical parameters, accurately predicted the need for plasma and cryoprecipitate transfusion, MT, and 24h mortality. ROTEM however, did not predict RBC or platelet transfusion. The results of our studies indicate that ROTEM may assist in the early diagnosis and guide timely management of bleeding coagulopathic injured patients. While our findings warrant future evaluations we speculate that ROTEM can guide blood transfusions, reduce inappropriate blood utilization and improve patient outcome (reduce mortality).

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