Goal-directed therapy in trauma induced coagulopathy and focus on traumatic brain injury

Klaus Görlinger

DOI: https://doi.org/10.7175/rhc.v4i3S.877


In recent years there have been major advances in the management of trauma-induced coagulopathy (TIC) and many experiences have demonstrated how we can achieve significant improvements with multidisciplinary approach and implementation of standardized protocols and algorithms. Central nervous system injuries and exanguination remain the primary causes of early trauma-related mortality. Traumatic brain injuries (TBI) make hemostasis in TIC even more complex and it is known that the onset of coagulopathy in a patient with severe brain injury has a negative impact on the patient’s outcome in terms of mortality. Standard coagulation tests provide limited information on coagulation disorder. The advantages of whole-blood viscoelastic tests, such as rotational thromboelastometry or thrombelastography, are shorter turn-around time and better diagnostic performance compared to routine plasmatic coagulation tests. In contrast to a fixed ratio of FFP:PC:RBC, the aim of the goal-directed coagulation therapy is to set treatment to the actual needs of the individual patient, based on viscoelastic test results. This article describes the improvements achieved through the implementation of ROTEM-guided treatment algorithms for visceral surgery and liver trasplantation, severe trauma and post-partum hemorrhage and cardiovascular surgery.


Goal-directed therapy; Trauma induced coagulopathy (TIC); Traumatic brain injury (TBI); ROTEM®

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  • Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995; 38: 185-93; http://dx.doi.org/10.1097/00005373-199502000-00006
  • Wafaisade A, Lefering R, Tjardes T, et al; Trauma Registry of DGU. Acute coagulopathy in isolated blunt traumatic brain injury. Neurocrit Care 2010; 12: 211-9; http://dx.doi.org/10.1007/s12028-009-9281-1
  • Schöchl H, Solomon C, Traintinger S, et al. Thromboelastometric (ROTEM) findings in patients suffering from isolated severe traumatic brain injury. J Neurotrauma 2011; 28: 2033-41; http://dx.doi.org/10.1089/neu.2010.1744
  • Lustenberger T, Talving P, Kobayashi L, et al. Time course of coagulopathy in isolated severe traumatic brain injury. Injury 2010; 41: 924-8; http://dx.doi.org/10.1016/j.injury.2010.04.019
  • Laroche M, Kutcher ME, Huang MC, et al. Coagulopathy after traumatic brain injury. Neurosurgery 2012; 70: 1334-45; http://dx.doi.org/10.1227/NEU.0b013e31824d179b
  • Chan CM, Zilberberg MD. Preferences in traumatic intracranial hemorrhage: bleeding vs. clotting. Crit Care 2010; 14: 153; http://dx.doi.org/10.1186/cc8996
  • Kiphuth IC, Staykov D, Köhrmann M, et al. Early administration of low molecular weight heparin after spontaneous intracerebral hemorrhage. A safety analysis. Cerebrovasc Dis 2009; 27: 146-50; http://dx.doi.org/10.1159/000177923
  • Adamzik M, Eggmann M, Frey UH, et al. Comparison of thromboelastometry with procalcitonin, interleukin 6, and C-reactive protein as diagnostic tests for severe sepsis in critically ill adults. Crit Care 2010; 14: R178; http://dx.doi.org/10.1186/cc9284
  • Solomon C, Traintinger S, Ziegler B, et al. Platelet function following trauma. A multiple electrode aggregometry study. Thromb Haemost 2011; 106: 322-30; http://dx.doi.org/10.1160/TH11-03-0175
  • Davenport R, Manson J, De’Ath H, et al. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med 2011; 39: 2652-8
  • Schöchl H, Cotton B, Inaba K, et al. FIBTEM provides early prediction of massive transfusion in trauma. Crit Care 2011; 15: R265; http://dx.doi.org/10.1186/cc10539
  • Haas T, Spielmann N, Mauch J, et al. Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery. Br J Anaesth 2012; 108: 36-41; http://dx.doi.org/10.1093/bja/aer342
  • Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 2007; 62: 112-9; http://dx.doi.org/10.1097/01.ta.0000250497.08101.8b
  • Bochicchio GV, Napolitano L, Joshi M, et al. Outcome analysis of blood product transfusion in trauma patients: a prospective, risk-adjusted study. World J Surg 2008; 32: 2185-9; http://dx.doi.org/10.1007/s00268-008-9655-0
  • Inaba K, Branco BC, Rhee P, et al. Impact of ABO-identical vs ABO-compatible nonidentical plasma transfusion in trauma patients. Arch Surg 2010; 145: 899-906; http://dx.doi.org/10.1001/archsurg.2010.175
  • Shanwell A, Andersson TM, Rostgaard K, et al. Post-transfusion mortality among recipients of ABO-compatible but non-identical plasma. Vox Sang 2009; 96: 316-23; http://dx.doi.org/10.1111/j.1423-0410.2009.01167.x
  • Khan H, Belsher J, Yilmaz M, et al. Fresh-frozen plasma and platelet transfusions are associated with development of acute lung injury in critically ill medical patients. Chest 2007; 131: 1308-14; http://dx.doi.org/10.1378/chest.06-3048
  • Waydhas C, Görlinger K. Coagulation management in multiple trauma. Unfallchirurg 2009; 112: 942-50; http://dx.doi.org/10.1007/s00113-009-1681-3
  • Görlinger K, Fries D, Dirkmann D, et al. Reduction of Fresh Frozen Plasma Requirements by Perioperative Point-of-Care Coagulation Management with Early Calculated Goal-Directed Therapy. Transfus Med Hemother 2012; 39: 104-113; http://dx.doi.org/10.1159/000337186
  • Schöchl H, Nienaber U, Maegele M, et al. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care 2011; 15: R83; http://dx.doi.org/10.1186/cc10078
  • Holcomb JB. Traditional transfusion practices are changing. Crit Care 2010; 14: 162; http://dx.doi.org/10.1186/cc9009
  • Görlinger K, Dirkmann D, Hanke AA, et al. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion in cardiovascular surgery: a retrospective, single-center cohort study. Anesthesiology 2011; 115: 1179-91
  • Weber CF, Görlinger K, Meininger D, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117: 531-47; http://dx.doi.org/10.1097/ALN.0b013e318264c644


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