„Keep Calm and Stop Bleeding”
Thromboelastometry identifies trauma-induced coagulopathy is a is characterized by EXTEM A5 ≤ 35 mm. This predicts massive transfusion at emergency room admission. Here, evidence-based ROTEM algorithms developed and refined on the results of several observational and interventional trauma studies are useful to detect hemostatic disorders and to guide hemostatic therapy in bleeding trauma patients. This also includes the detection of anticoagulants and the management of coagulopathy associated with these drugs.
It is essential that an initial ROTEM analysis is performed as soon as the patient arrives in the emergency room to avoid inappropriate blood transfusion in non-coagulopathic patients and to guide hemostatic therapy in coagulopathic trauma patients. Here, the ROTEM trauma algorithm considers and manages different coagulopathies in the sequence of importance: hyperfibrinolysis, clot firmness issues (fibrinogen and platelets), and thrombin generation issues (enzymatic factor deficiencies and anticoagulants).
Pharmacologic hemostatic interventions such as tranexamic acid, fibrinogen concentrate, and prothrombin complex concentrate have been shown to be more effective compared to fresh frozen plasma in treating trauma-induced coagulopathy, particularly if guided by an evidence-based ROTEM algorithm. Furthermore, the implementation of ROTEM-guided algorithms in trauma has been shown to decrease the incidence of thromboembolic events by about 50% which is an important safety aspect.
An increasing number of cohort studies and randomized controlled trials demonstrate the benefit of viscoelastic testing guided bleeding management in military as well as civilian trauma. Accordingly, the Eastern Association for the Surgery of Trauma (east) in the US showed in their practice management guideline that ROTEM/TEG-guided bleeding management is associated with a risk ratio for mortality of 0.75 (95% CI, 0.59-0.95; P = 0.02). Authors reporting on bleeding management in military trauma are recommending viscoelastic testing as the new standard for trauma resuscitation, too. In between, 22 interventional studies including 8437 trauma patients have been published with a consistent risk ratio for mortality of 0.71 (95% CI, 0.57-0.87; P = 0.001) in the ROTEM/TEG group.
