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The “Death Diamond”: Rapid thrombelastography identifies lethal hyperfibrinolysis

Chapman, Michael P. MD; Moore, Ernest E. MD; Moore, Hunter B. MD; Gonzalez, Eduardo MD; Morton, Alexander P. MD; Chandler, James; Fleming, Courtney D.; Ghasabyan, Arsen MPH; Silliman, Christopher C. MD, PhD; Banerjee, Anirban PhD; Sauaia, Angela MD, PhD

Journal of Trauma and Acute Care Surgery: December 2015 - Volume 79 - Issue 6 - p 925–929
doi: 10.1097/TA.0000000000000871
WTA Plenary Papers

BACKGROUND Postinjury hyperfibrinolysis (HF), defined as LY30 of 3% or greater on rapid thrombelastography (rTEG), is associated with high mortality and large use of blood products. We observed that some cases of HF are reversible and are associated with patients who respond to hemostatic resuscitation; however, other cases of severe HF seem to be associated with these patients’ inevitable demise. We therefore sought to define this unsurvivable subtype of HF as a recognizable rTEG tracing pattern.

METHODS We queried our trauma registry for patients who either died or spent at least 1 day in the intensive care unit, received at least 1 U of packed red blood cells, and had an admission rTEG. Within this group of 572 patients, we identified 42 pairs of nonsurvivors and survivors who matched on age, sex, injury mechanism, and New Injury Severity Score (NISS). We inspected the rTEG tracings to ascertain if any pattern was found exclusively within the nonsurviving group and applied these findings to the cohort of 572 patients to assess the predictive value for mortality.

RESULTS Within the matched group, 17% of the patients developed HF. Within the HF subgroup, a unique rTEG pattern was present in 14 HF patients who died and in none of the survivors. This pattern was a “diamond-shaped” tracing with a short time to maximum amplitude of 14 minutes or shorter and complete lysis before the LY30 point. When these criteria are applied to the 572 unmatched patients, this pattern had a 100% positive predictive value for mortality.

CONCLUSION Patients displaying the “death diamond” pattern on their admission rTEG are at higher risk for mortality. Given the volume of blood products and other resources that these patients consume, this thrombelastography pattern may represent an objective criterion to discontinue efforts at hemostatic resuscitation.

LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

From the Department of Surgery (M.P.C., E.E.M., J.C., C.D.F., H.B.M., E.G., A.P.M., A.G., C.C.S., A.B., A.S.), University of Colorado Denver; Department of Surgery, Denver Health Medical Center (M.P.C., E.E.M., J.C., C.D.F., H.B.M., E.G., A.P.M., A.G.), Denver; and Bonfils Blood Center (C.C.S.), and Department of Hematology and Oncology (C.C.S.), Children’s Hospital Colorado, Aurora, Colorado; Department of Surgery, Georgia Regents University (M.P.C.), Augusta, Georgia.

Submitted: February 23, 2015, Revised: August 19, 2015, Accepted: August 25, 2015, Published online: October 19, 2015.

This study was presented at the 45th annual meeting of the Western Trauma Association, March 1–6, 2015, in Telluride, Colorado.

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health and the Department of Defense or any of our industry sponsors.

Address for reprints: Ernest E. Moore, MD, Department of Surgery, Denver Health Medical Center, 777 Bannock St, Denver, CO 80204; email:

© 2015 Lippincott Williams & Wilkins, Inc.