Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate.
BACKGROUND
The appropriate strategy for trauma-induced coagulopathy management is under debate. We report the treatment of major trauma using mainly coagulation factor concentrates.


METHODS
This retrospective analysis included trauma patients who received >or= 5 units of red blood cell concentrate within 24 hours. Coagulation management was guided by thromboelastometry (ROTEM). Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after fibrinogen concentrate administration was an indication for platelet concentrate. The observed mortality was compared with the mortality predicted by the trauma injury severity score (TRISS) and by the revised injury severity classification (RISC) score.


RESULTS
Of 131 patients included, 128 received fibrinogen concentrate as first-line therapy, 98 additionally received PCC, while 3 patients with recent coumarin intake received only PCC. Twelve patients received FFP and 29 received platelet concentrate. The observed mortality was 24.4%, lower than the TRISS mortality of 33.7% (P = 0.032) and the RISC mortality of 28.7% (P > 0.05). After excluding 17 patients with traumatic brain injury, the difference in mortality was 14% observed versus 27.8% predicted by TRISS (P = 0.0018) and 24.3% predicted by RISC (P = 0.014).


CONCLUSIONS
ROTEM-guided haemostatic therapy, with fibrinogen concentrate as first-line haemostatic therapy and additional PCC, was goal-directed and fast. A favourable survival rate was observed. Prospective, randomized trials to investigate this therapeutic alternative further appear warranted.
Schöchl
Herbert
H
Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Dr Franz-Rehrl-Platz 5, Salzburg, Austria. Herbert.Schoechl@auva.at
Nienaber
Ulrike
U
Hofer
Georg
G
Voelckel
Wolfgang
W
Jambor
Csilla
C
Scharbert
Gisela
G
Kozek-Langenecker
Sibylle
S
Solomon
Cristina
C
D000328:Adult; D001779:Blood Coagulation Factors / Q000627:therapeutic use; D005260:Female; D005340:Fibrinogen / Q000008:administration & dosage / Q000627:therapeutic use*; D006470:Hemorrhage / Q000188:drug therapy; D006489:Hemostatic Techniques; D006801:Humans; D008297:Male; D008875:Middle Aged; D011516:Prothrombin / Q000008:administration & dosage / Q000627:therapeutic use*; D012189:Retrospective Studies; D013916:Thrombelastography / Q000379:methods*; D014947:Wounds and Injuries / Q000097:blood*
D001779:Blood Coagulation Factors; D011516:Prothrombin; D005340:Fibrinogen