The document discusses trauma management and coagulation monitoring using viscoelastic hemostatic assays (VHAs) like ROTEM. It provides details about a large trauma network in Germany serving over 5 million people, which has used ROTEM since 1999. The network includes two air ambulances and level 1 trauma centers. The document then discusses how ROTEM is used to guide treatment for bleeding patients, focusing on substituting fibrinogen, prothrombin complex concentrates, platelets, and tranexamic acid based on ROTEM results. Mortality rates from major trauma trials using different resuscitation strategies are presented. Examples of trauma cases treated using goal-directed coagulation management guided by ROTEM are also provided.

1. How we treat bleeding patients
The non surgical perspective
Essen style

2. Who uses Viscoelastic hemostatic assays?

3. Who uses factor concentrates?

4. @rocu_bene
Anesthesiologist
Intensivist
Emergency physician
with:
NO CONFLICT OF INTERESTS

5. But we use ROTEM in our hospital since:
1999

8. The German Trauma Network in the Region

9. The German Trauma Network in the Region
RUHR POTT

11. The German Trauma Network in the Region
Population: 5,1 Millionen people

12. The German Trauma Network in the Region
Population: 5,1 Millionen people

13. The German Trauma Network in the Region
Population: 5,1 Millionen people

14. The German Trauma Network in the Region
Population: 5,1 Millionen people
(c) J. Dahmen

15. The German Trauma Network in the Region
Population: 5,1 Millionen people
Christoph 9 since 1975
Christoph 8 since 1978

16. The German Trauma Network in the Region
Population: 5,1 Millionen people
Christoph 9 since 1975
Christoph 8 since 1978
BGU Trauma Center Duisburg
Bergmannsheil Bochum
the oldest Trauma hospital in the world
Bergmannsheil Buer

17. Why is it necessary to transfuse as little blood as possible?
Social reasons
20
40
60
80
100
1980 1990 2000 2010 2020 2030 2040 2050 2060
Age
Life expectancy Germany

18. Why is it necessary to transfuse as little blood as possible?
Social reasons
20
40
60
80
100
198020102040
Silver Tsunami

19. Why is it necessary to transfuse as little blood as possible?
Social reasons
20
40
60
80
100
198020102040
Silver Tsunami
We will run out of blood!

20. Why is it necessary to transfuse as little blood as possible?
Medical reasons

21. Why is it necessary to transfuse as little blood as possible?
Medical reasons
Airplane: per flight
Lightning: per year
Traffic: per 10K inhabitants & year
Medical error: per hospital admission
FNHTR febrile nonhemolytic transfusion reaction
DHTR delayed hemolytic transfusion reaction
AHTR acute hemolytic transfusion reaction
Carson JL et al. N Engl J Med 2017; 377:1261-72

22. Why is it necessary to transfuse as little blood as possible?
Medical reasons

23. Why is it necessary to transfuse as little blood as possible?
Medical reasons

24. Why is it necessary to transfuse as little blood as possible?
Medical reasons
Patient blood management is an evidence based procedure
to reduce the need for blood transfusion

25. The crux of transfusion
• 2,3-DPG is low
• Decreased deformability of pRBC
• pRBC tranfusion did not increase oxygen uptake in critical ill patients
• Liberal vs restrictive transfusion triggers show no advantages for
those patient who received more blood
• PBM is associated reduced transfusion need of red blood cell units,
lower complication and mortality rate, and thereby improving clinical
outcome
Int J Mol Sci. 2017 Sep 11;18(9). pii: E1946. doi: 10.3390/ijms18091946.
Transfusion of Red Blood Cells to Patients with Sepsis.
Chan YL1, Han ST2, Li CH3, Wu CC4, Chen KF5,6,7,8.

26. The crux of transfusion
• 2,3-DPG is low
• Decreased deformability of pRBC
• pRBC tranfusion did not increase oxygen uptake in critical ill patients
• Liberal vs restrictive transfusion triggers show no advantages for
those patient who received bmore blood
• PBM is associated reduced transfusion need of red blood cell units,
lower complication and mortality rate, and thereby improving clinical
outcome
Int J Mol Sci. 2017 Sep 11;18(9). pii: E1946. doi: 10.3390/ijms18091946.
Transfusion of Red Blood Cells to Patients with Sepsis.
Chan YL1, Han ST2, Li CH3, Wu CC4, Chen KF5,6,7,8.
(C) H. Schöchl

27. The risk of transfusion
Typical side effects are:
• Hemolytic Transfusion Reactions
• Febrile Non-Hemolytic Reactions
• Allergic Reactions ranging from urticaria to anaphylaxis
• Septic Reactions (warm fluid!)
• Transfusion Related Acute Lung Injury (TRALI) Circulatory Overload
• Transfusion Associated Graft Versus Host Disease Post-transfusion
Purpura

28. The crux of transfusion
Plasma transfusion:
Sarani, Crit Care Med 2008, 36, 1114-1118

29. The crux of transfusion
Plasma transfusion:
• Increased risk of ARDS, MOF
• Large volume is needed
• High risk of TRALI, TACO
• Only 5% can donor AB - Plasma
Injury: July 2011Volume 42, Issue 7, Pages 697–701Higher rate of Multi organ failure retrospective

30. How to measure good
coagulation management?

31. Per year:
• 28.000 anesthetic procedures
• 2400 intracranial operation
• 1500 OP with cardiopulmonary bypass
• National Center for Aortic dissection
• >120 Liver transplantation
• 50 Lung transplantation
• Biggest sarcoma Center in GER
• Biggest Hospital in the Region
• Busiest Trauma Center in the Region

32. Per year:
• 28.000 anesthetic procedures
• 2400 intracranial operation
• 1500 OP with cardiopulmonary bypass
• National Center for Aortic dissection
• >120 Liver transplantation
• 50 Lung transplantation
• Biggest sarcoma Center in GER
• Biggest Hospital in the Region
• Busiest Trauma Center in the Region
MASS TRANSFUSION
(>10U of RBC)
in 2018:

33. The university hospital Essen
ROTEM @ the Department of anethesiology
22 bed anesthesiological ICU + ECMO center
OP Center 2
OP Center 1
OB/Gyn
PACU/Trauma
❤
🔪🔪
Laboratory

35. How does ROTEM work
(c) K. Görlinger

36. How to interpret ROTEM?

37. The „Essener Runde“ algorithm

38. The „Essener Runde“ algorithm
Check:
Calcium conzentration?
Bodytemperature?
Von Willebrand disease
Thrombocytopathies?
Clopidogrel?
ASS?
START a multiplate analysis!

39. The „Essener Runde“ algorithm
Check:
HEPARIN effect?
CHECK HEPTEM
www.essener-runde.de

40. How we treat bleeding patients with pathological findings in ROTEM
vs

41. How we treat bleeding patients with pathological findings in ROTEM
Early signs of hyperfibrinolysis:
A5EXTEM <35mm
CTFIBTEM>600s
ML>5%
TXA

42. 1 fact about tranexamic acid
Use it!

43. How we treat bleeding patients with pathological findings in ROTEM
Fibrinogen

44. How we treat bleeding patients with pathological findings in ROTEM

45. How we treat bleeding patients with pathological findings in ROTEM
Hagemo J, et al. Critical Care 2014;18:R52
Fibrinogen concentration
< 2.29 g/l
on arrival is strongly
related to poor outcome
Low MCF in ROTEM is
associated with increased
blood loss, more blood
transfusion and higher
mortality
Fibrinogen
Rourke et al. J Thromb Haemost 2012

46. How we treat bleeding patients with pathological findings in ROTEM
Findings From the MATTERs II Study
Jonathan J. Morrison
Fibrinogen

47. How we treat bleeding patients with pathological findings in ROTEM
How to substitute
Fibrinogen?
British Journal of Anaesthesia 113 (4): 585–95 (2014)
Fibrinogen
Plasma can not
effectively restore
coagulation factor
loss!
Plasma causes
dilution and
increases the
transfusion
requirement

48. How we treat bleeding patients with pathological findings in ROTEM
Plasma alone is not effektive to treat (trauma induced) coagulopathy
Plasma alone is not effective to increase the Fibrinogen level.
Plasma is (not more than) a volume expander with positive effect on (the the surrogate
parameter of) glycocalyx (shredding)!
Fibrinogen
Cryo or Concentrate?
In Cryostat-1 it took 90 minutes so give 1st dose of Cryo
In RETIC it took 10 minutes to achieve good coagulation

49. How we treat bleeding patients with pathological findings in ROTEM
How to substitute
Fibrinogen?
Fibrinogen

50. How we treat bleeding patients with pathological findings in ROTEM
How to substitute
Fibrinogen? 2,3 g/l
Fibrinogen

51. How we treat bleeding patients with pathological findings in ROTEM
Fibrinogen
Vs

52. How we treat bleeding patients with pathological findings in ROTEM
CT depends on the availability of fibrinogen!
Prothrombin Complex

53. How we treat bleeding patients with pathological findings in ROTEM
PPSB = PCCProthrombin Complex

54. How we treat bleeding patients with pathological findings in ROTEM
PPSB = PCC
FFP transfusion could correct Prothrombin time.
Abdel-Wahab, Transfusion 2006; 46: 1279
Prothrombin Complex

55. How we treat bleeding patients with pathological findings in ROTEM
PPSB = PCC
FFP transfusion could correct Prothrombin time.
Abdel-Wahab, Transfusion 2006; 46: 1279
Prothrombin Complex

56. How we treat bleeding patients with pathological findings in ROTEM
PPSB = PCC

57. How we treat bleeding patients with pathological findings in ROTEM
🇩🇩🇩🇩PPSB = PCC 🇺🇺🇺🇺
😎😎

58. How we treat bleeding patients with pathological findings in ROTEM
🇩🇩🇩🇩PPSB = PCC 🇺🇺🇺🇺
😎😎

59. How we treat bleeding patients with pathological findings in ROTEM
Platelets

60. How we treat bleeding patients with pathological findings in ROTEM
Fibrinogen or Cryo
PPSB/PCC
Platelets
Tranexamic acid (should be 1st!)

61. Where the clot is, the embolism is not far

62. Where the cot is, the embolism is not far

63. Some examples

64. Trauma

65. (c) by Dr. M. Britten, Essen
Trauma

66. Trauma
Repeat ROTEM after factor substitution
Repeat ROTEM every 30 minutes
1st. line Volume:
RBC and 4% succinylated Gelatin,
Physiological cristalloïdes
Repeat TXA 2 g
Give Fibrinogen
Give platelets
Give PPSB
Don´t forget:
Ca2+, Body temperature, hematocrit

67. Prehospital:
😱😱 1500ml crystalloids 😱😱
Resus Room:
2 g TXA
100mg/kgBW FibC
2 U platelets
Trauma
FIBTEM A10: 24mm!

68. Evidence?

69. Trauma
ISS Mortality
🇺🇺🇺🇺 Holcomb et al., PROPPR
JAMA 2015
25 24 %
🇺🇺🇺🇺
Holcomb et al.
PROMMTT
JAMA 2013
25,5 21,4-25%
🇺🇺🇺🇺 Sperry et al.
PAMPer
22 // 21 23-33%
🇦🇦🇦🇦 Schöchl et al.
Crit Care 2011
35 7,5-10%
🇦🇦🇦🇦 Innerhofer et al.
Injury 2013
37,5 5-6%
🇦🇦🇦🇦 Innerhofer, RETIC
Lancet Hem. 2017
34 7,4 %
🇯🇯🇯🇯
Yamamoto et al.
Trauma Surgery 2016 >41 20 %
Yamamoto et al.
Trauma Surgery 2016 >41 50 %
+ cFIB
- cFIB
FFP/PRBC
ROTEM + CFC
ROTEM + CFC
ROTEM + CFC
ROTEM + CFC

70. 69 year old patient hit by car:
38 units of LTOWB
13 units of RBCs,
12 units of fresh frozen plasma,
2 packs of platelets, and
2 units of cryoprecipitate,
Trauma
„Thrombelastography performed during
the resuscitation revealed […]
decreased clot strength…“

71. What is the difference between both pics?

72. TraumaISS Mortality
🇺🇺🇺🇺 Holcomb et al., PROPPR
JAMA 2015
25 24 %
🇺🇺🇺🇺
Holcomb et al.
PROMMTT
JAMA 2013
25,5 21-25%
🇺🇺🇺🇺 Sperry et al.
PAMPer
22 // 21 23-33%
🇦🇦🇦🇦 Schöchl et al.
Crit Care 2011
35 7,5-10%
🇦🇦🇦🇦 Innerhofer et al.
Injury 2013
37,5 5-6%
🇦🇦🇦🇦 Innerhofer, RETIC
Lancet Hem. 2017
34 7,4 %
🇺🇺🇺🇺 Seheult et al. Transfusion med.
2019
22 24,4 %
🇺🇺🇺🇺 Seheult et al. Transfusion med.
2019
21 18,5 %
🇺🇺🇺🇺 BA Cotton et al.
Annals of surgery 2013
22 22-27%
BA Cotton et al.
LTOWB
1:1:1
mWB
No TBI + mWB

73. Trauma
(C) by J. Dahmen