Prevalence and impact of abnormal ROTEM® assays in severe blunt trauma: results of the 'Diagnosis and Treatment of Trauma-Induced Coagulopathy (DIA-TRE-TIC) study'

Background. ROTEM (R)/TEG (R) (rotational thromboelastometry) assays appear to be useful for the treatment of bleeding trauma patients. However, data on the prevalence and impact of abnormal ROTEM (R) assays are scarce. Methods. This is a prospective cohort study of blunt trauma patients (Injury Severity Score >= 15 or Glasgow Coma Score <= 14) admitted to Innsbruck Medical University Hospital between July 2005 and July 2008. Standard coagulation tests, antithrombin (AT), prothrombin fragments (F1 + 2), thrombin-antithrombin complex (TAT), and ROTEM (R) assays were measured after admission. Data on 334 patients remained for final analysis. Results. ROTEM (R) parameters correlated with standard coagulation tests (all Spearman r > 0.5), and significant differences in mortality were detected for defined ROTEM (R) thresholds [FIBTEM 7 mm (21% vs 9%, P=0.006), EXTEM MCF (maximum clot firmness) 45 mm (25.4% vs 9.4%, P=0.001)]. EXTEM MCF was independently associated with early mortality [odds ratio (OR) 0.94, 95% confidence interval (CI) 0.9-0.99] and MCF FIBTEM with need for red blood cell transfusion (OR 0.92, 95% CI 0.87-0.98). In polytrauma patients with or without head injury (n=274), the prevalence of low fibrinogen concentrations, impaired fibrin polymerization, and reduced clot firmness was 26%, 30%, and 22%, respectively, and thus higher than the prolonged international normalized ratio (14%). Hyperfibrinolysis increased fatality rates and occurred as frequently in isolated brain injury (n=60) as in polytrauma (n=274) (5%, 95% CI 1.04-13.92 vs 7.3%, 95% CI 4.52-11.05). All patients showed elevated F1 + 2 and TAT and low AT levels, indicating increased thrombin formation. Conclusions. Our data enlarge the body of evidence showing that ROTEM (R) assays are useful in trauma patients. Treatment concepts should focus on maintaining fibrin polymerization and treating hyperfibrinolysis.