The Role of TEG and ROTEM in Damage Control Resuscitation

Abstract

Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.

Fig. 1

Flowchart of the review design and results of literature search.

Fig. 2

Comparison of TEG and ROTEM tracings to demonstrate their similarities. TEG indicates thrombelastography; ROTEM, rotational thromboelastometry; R, reaction time; CT, clotting time; k, k-time or kinetics; CFT, clot formation time; α, alpha-angle; MA, maximum amplitude; MCF, maximum clot firmness; LY30, lysis at 30 min; CL30, clot lysis at 30 min.