Thrombelastography for Management of Non-Traumatic Hemorrhagic Shock
The use of thrombelastography (TEG, ROTEM) has traditionally been utilized and studied in the management of acute coagulopathy of trauma (ACoT) developed by patients in hemorrhagic shock secondary to trauma.
Functional coagulation tests such as the TEG may provide valuable information when resuscitating the hemorrhaging patient, especially if there is any concern for an underlying coagulopathy.
The following is a TEG recently returned during the resuscitation of a 60 y/o male with a history of HCV cirrhosis presenting with hemorrhagic shock secondary to a massive upper GIB. The University's Massive Transfusion Protocol was promptly activated and at this point, the patient had received approximately 4 units of PRBCs & FFP along with 1 liter of crystalloid. His Hgb was 5, PT/PTT/INR were undetectable, and his fibrinogen was 80.
Below is a table that simplifies the treatment, based on the test's abnormalities:
After reviewing the initial TEG, all perameters were abnormal in addition to the presence of significant fibrinolysis. The patient was given an additional 4 units of FFP, DDAVP, cryoprecipitate, a unit of platelets, and aminocaproic acid. The patient still required significant resuscitation, however bleeding had significantly decreased as well has his pressor requirement. Below is the patient's follow-up TEG 2 hours later.
There is growing enthusiasm for the use of functional coagulopathy testing in the patient with hemorrhagic shock. Early resuscitation with blood products as your fluid of choice with limited fluid administration while arranging for definitive source control are critical, but also consider early thrombelastography to detect additional causes for uncontrolled hemorrhage.
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