Trauma-induced coagulopathy. A narrative review of goal-directed hemostatic resuscitation

Post-traumatic haemorrhage is the leading cause of death in trauma patients. The development of coagulopathy substantially contributes to bleeding severity and to the ensuing unfavourable outcome. Trauma-induced coagulopathy (TIC) can be seen in 10-25% of patients with major trauma, and its early and appropriate therapeutic management leads to considerable reduction of mortality risk. Due to the extreme complexity of TIC pathophysiology, the limitations of conventional coagulation tests (CCTs) have become evident in recent years. Unlike these routine tests, point of care viscoelastic tests (VET) such as thromboelastogram (TEG) or rotational thromboelastography (ROTEM) provide valuable clinical information by real time assessment of changes in viscoelastic properties of blood throughout clot formation. This review was aimed to collect and discuss available evidence on goal-directed hemostatic resuscitation, based on TEG or ROTEM data. We included studies with patients aged 18 years or older, major trauma, and needing massive transfusions. Overall, 6 studies totalling 1533 patients were finally included. A total number of 288 patients died, 98 of whom in the TEG- or ROTEM-guided cohorts (i.e., intervention groups). A 36% reduction of death was observed in the intervention groups (relative risk, 0.641; 95% CI 0.517-0.795; P<0.001). Our results show that VET-guided management is effective to reduce mortality compared to conventional management with CCTs. Except for mortality, all others endpoints were heterogeneous across the studies. This emphasize the need of scheduling new and well-designed trials, aimed to better define the optimal strategy for TIC management.