title: Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients.
abstract: OBJECTIVE
  Injury and shock lead to alterations in conventional coagulation tests (CCTs). Recently, rapid thrombelastography (r-TEG) has become recognized as a comprehensive assessment of coagulation abnormalities. We have previously shown that admission r-TEG results are available faster than CCTs and predict pulmonary embolism. We hypothesized that r-TEGs more reliably predict blood component transfusion than CCTs.
  
  
  METHODS
  Consecutive patients admitted between September 2009 and February 2011 who met the highest-level trauma activations were included. All had admission r-TEG and CCTs. We correlated r-TEG values [activated clotting time (ACT), r, k, α, maximal amplitude (MA), LY30] with their corresponding CCTs [prothrombin time (PT)/activated partial thromboplastin time (aPTT), international normalized ratio (INR), platelet count and fibrinogen] for transfusion requirements. Charges were calculated for each test. Demographics, vital signs, and injury severity were recorded.
  
  
  RESULTS
  We studied 1974 major trauma activations. The median injury severity score was 17 [interquartile range 9-26]; 25% were in shock; 28% were transfused; and 6% died within 24 hours. Overall, r-TEG correlated with CCTs. When controlling for age, injury mechanism, weighted-Revised Trauma Score, base excess and hemoglobin, ACT-predicted red blood cell (RBC) transfusion, and the α-angle predicted massive RBC transfusion better than PT/aPTT or INR (P < 0.001). The α-angle was superior to fibrinogen for predicting plasma transfusion (P < 0.001); MA was superior to platelet count for predicting platelet transfusion (P < 0.001); and LY-30 (rate of amplitude reduction 30 minutes after the MA is reached) documented fibrinolysis. These correlations improved for transfused, shocked or head injured patients. The charge for r-TEG ($317) was similar to the 5 CCTs ($286).
  
  
  CONCLUSIONS
  The r-TEG data was clinically superior to results from 5 CCTs. In addition, r-TEG identified patients with an increased risk of early RBC, plasma and platelet transfusions, and fibrinolysis. Admission CCTs can be replaced with r-TEG.
authors.affiliation: Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA. John.Holcomb@uth.tmc.edu
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Minei
authors.forename: Michelle L
authors.initials: ML
authors.lastname: Scerbo
authors.forename: Zayde A
authors.initials: ZA
authors.lastname: Radwan
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: Rosemary A
authors.initials: RA
authors.lastname: Kozar
authors.forename: Brijesh S
authors.initials: BS
authors.lastname: Gill
authors.forename: Rondel
authors.initials: R
authors.lastname: Albarado
authors.forename: Michelle K
authors.initials: MK
authors.lastname: McNutt
authors.forename: Saleem
authors.initials: S
authors.lastname: Khan
authors.forename: Phillip R
authors.initials: PR
authors.lastname: Adams
authors.forename: James J
authors.initials: JJ
authors.lastname: McCarthy
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
mesh_terms: D000328:Adult; D001778:Blood Coagulation Disorders / Q000175:diagnosis* / Q000209:etiology; D001780:Blood Coagulation Tests / Q000191:economics; D016913:Blood Component Transfusion / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000628:therapy*; D017721:Hospital Costs; D006801:Humans; D015601:Injury Severity Score; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies; D013781:Texas; D013916:Thrombelastography / Q000191:economics / Q000379:methods; D014947:Wounds and Injuries / Q000150:complications* / Q000401:mortality