Background

Trauma hemorrhage induces a coagulopathy with a high associated mortality rate. The Implementing Treatment Algorithms for the Correction of Trauma Induced Coagulopathy (ITACTIC) randomized trial tested two goal-directed treatment algorithms for coagulation management: one guided by conventional coagulation tests and one by viscoelastic hemostatic assays (viscoelastic). The lack of a difference in 28-day mortality led the authors to hypothesize that coagulopathic patients received insufficient treatment to correct coagulopathy.

Methods

During ITACTIC, two sites were coenrolling patients into an ongoing prospective observational study, which included serial blood sampling at the same intervals as in ITACTIC. The subgroup in both studies had conventional and viscoelastic test results for each patient available for analysis. A goal-directed treatment was defined as one triggered by an ITACTIC algorithm. Coagulopathy was defined as rotational thromboelastometry EXTEM A5 less than 40 mm. The primary outcome was correction of coagulopathy by the 12th unit of erythrocyte transfusion during resuscitation.

Results

Full viscoelastic and conventional coagulation test results were available for 133 patients. Of these patients, 71% were coagulopathic on admission, and 16% developed a coagulopathy during resuscitation. ITACTIC viscoelastic hemostatic assay group patients were more likely to receive goal-directed treatment than the standard group (76% vs. 47%; odds ratio, 3.73; 95% CI, 1.64 to 8.49; P = 0.002). However, only 54% of patients received goal-directed treatment, and only 20% corrected their coagulopathy (vs. 0% with empiric treatment alone; not significant). Median time to first goal-directed treatment was 68 (53 to 88) min for viscoelastic and 110 (77 to 123) min for standard (P = 0.005).

Conclusions

In ITACTIC, many bleeding trauma patients did not receive an indicated goal-directed treatment. Interventions arrived late during resuscitation and were only partially effective at correcting coagulopathy.

Editor’s Perspective
What We Already Know about This Topic
  • Goal-directed treatment to treat trauma-induced coagulopathy is used to optimize treatment as the mortality rate is high; however, the optimal algorithm for bleeding management is unknown
  • The authors evaluated trauma-induced coagulopathy management strategies guided by conventional coagulation tests and viscoelastic hemostatic assays to determine whether one improved trauma-induced coagulopathy management as defined by coagulopathy correction by the 12th unit of erythrocyte transfusion
What This Article Tells Us That Is New
  • The study evaluated 133 patients; 71% were coagulopathic on admission, whereas 16% developed coagulopathy during resuscitation
  • The viscoelastic group received goal-directed therapy more often than conventional (76% vs. 47%), and only 20% corrected their coagulopathy (vs. 0% with empiric treatment alone) with time to first goal-directed treatment of 68 (53 to 88) min for the viscoelastic group and 110 (77 to 123) min for the conventional group
  • Many bleeding trauma patients did not receive indicated goal-directed treatment, and interventions arrived late during resuscitation and were only partially effective at correcting coagulopathy