Background: Treatment of bleeding in trauma patients is based on classical coagulation tests and on empiric rules. ROTEM, a modified thrombelastogram, allows rapid detection of hyperfibrinolysis, fibrinogen deficiency, and stability of the clot.
Goal of the Study: Establishing an algorithm using ROTEM parameters to target therapy with specific blood products or antifibrinolytic drugs to respond to causes of bleeding, which cannot be detected with classical coagulation tests.
Methods: From 2000 to 2005, 20,000 ROTEM measurements (trauma and non-trauma patients) were analyzed. Reference values of publications were also screened.
Results: Prophylactic aprotinin/tranexamic acid administration is indicated if Maximum Clot Firmness (MCF) of EXTEM (ex) < 35 mm on admission. Aprotinin/tranexamic acid is indicated if: Maximum Lysis (ML) > 10% at 30 minutes or > 15% at 60 minutes or if the ratio of Coagulation Time (CT) of APTEM (ap) to EXTEM < 0.75 and if the ratio of the Amplitude at 15min (A15) is A15-ap/A15-ex > 1.25. The cut-off point for fibrinogen administration is: MCF-ex < 50 mm with a MCF of FIBTEM (fib) < 12 mm. Platelet transfusion is indicated if MCF-ex < 50 mm and MCF-fib > 12 mm. Fresh frozen plasma or cryoprecipitates are given if CT-ex > 80 s or CT of INTEM (in) > 240 s and if CT of HEPTEM (hep) equals CT-in. Protamine is administered if CT-in > 240 s and CT-hep/CT-in < 0.66. Following parameters are needed to indicate treatment with rFVIIa: CT-ex, CT-in, CT-hep, MCF-ex, MCF-fib, ML (30 min), fibrinogen concentration, platelet count, pH.
Discussion: In bleeding trauma patients ROTEM allows the diagnosis of hyperfibrinolysis and a more targeted use of expensive blood products. ROTEM gives additional information to eliminate non-hematological causes for haemorrhage. The algorithm is a step to improve management of bleeding in trauma and needs to be validated by multicenter studies.
Conclusion: Diagnosis and treatment of haemorrhage in trauma, classical coagulation tests should be complemented with the ROTEM-analysis.