rTEG Based Goal Directed Hemostatic Resuscitation in High Risk Pediatric Trauma
Original Date: 11/2011 | Supersedes: 06/2016; 07/2019, 10/21 | Last Review Date: 3/2024 (Reviewed with no changes)
Purpose: Traumatic injury is a leading cause of morbidity and mortality in the pediatric population. This patient population often suffers from a coexisting, well-defined coagulopathy of trauma associated with severely injured patients. Reversing this coagulopathy with a return to normal coagulation parameters is an essential component of the resuscitation of the injured patient and is essential to preventing additional complications during invasive procedures such as laparotomy and intracranial pressure monitor placement. Thrombelastography (TEG) is a global measure of the viscioelastic properties of blood and global hemostatic function and is used in trauma patients to provide goal-directed guide physiologic and hemostatic resuscitation to restore normal physiology and coagulation. Rapid thrombelastography has been shown to correlate with conventional coagulation testing, is predictive of early transfusions of blood products, and is currently used to direct goal directed hemostatic resuscitation in pediatric trauma patients. This guideline serves as a model to provide goal directed hemostatic resuscitation of the pediatric trauma patient using rapid thrombelastography.
***USE OF TXA 3 HOURS OR MORE AFTER INJURY INCREASES MORTALITY AND IS NOT INDICATED
Procedure
| Normal | Abnormal Value | Primary Treatment | Secondary Treatment | |
|---|---|---|---|---|
| ACT | 86-118 | 118-150 | FFP (10 ml/kg) | |
| 150-170 | FFP (15 ml/kg) | rFVIIa (30 μg/kg) | ||
| >170 | FFP (20 ml/kg) | rFVIIa (60 μg/kg) | ||
| α | 64-80 | < 60 | Cryoprecipitate (10 ml/kg) | FFP (10-15 ml/kg), rFVIIa (30 μg/kg) |
| MA | 52-71 | 46-52 | DDAVP (0.3 units/kg) or Apheresis platelets (10 ml/kg) | |
| 40-46 | Apheresis platelets (10 ml/kg) | Cryoprecipitate (10 ml/kg) | ||
| < 40 | Apheresis platelets (10-15 ml/kg) | Cryoprecipitate (10 ml/kg) | ||
| LY30 | 0-7.5% | > 7.5% | Results ≥ 3% Consider Amicar 200 mg/kg or Tranexamic Acid 10 mg/kg IV | |
***USE OF TXA 3 HOURS OR MORE AFTER INJURY INCREASES MORTALITY AND IS NOT INDICATED***
rTEG normal values from MHH CARE4
Based on Spinella PC and Holcomb JB. Hemostatic Resuscitation: The Transfusion Approach to Hemorrhagic Shock. Current Concepts in Pediatric Critical Care. 2011.
CRASH-2 collaborators et al. (2011) The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. doi.org/10.1016/S0140-6736(11)60278-X