OUTLINE:I. Historical Perspective. A. Development of Thromboelastography.

B. The expansion and transition from Cardiac Surgery to Trauma.

II. Traditional Lab Tests vs. TEG tests.A. Clotting cascade B. Traditional Testing

1. Protime( (PT) 2. Partial thromboplastin time (PTT)

3. IVY bleeding time 4. Fibrinogen

III. Clinical use of Point-of-Care testing for TraumaA. POC Tests

1. TEG (platelet mapping, V-curve, Rapid TEG) 2. I-stat (ph,pCO2,PO2,HCO3-,BE/BD,iCa2+,Hb/Hct,K+,Gluc.)B. Indications for POC.

1. Massive Transfusion 2. Head Injuries

3. Isolated Coagulopathies from Trauma related events.

IV. Clinical Findings with the TEG A. Native TEG tracings B. Platelet Mapping and effects of drugs and the Interpretations. C. V- curve

Why Do we have a Perfusionist talking about Trauma?

Training ExperienceUse of the TEG in Cardiac Surgery Similarities between Cardiac Surgery/

TraumaLessons learned with TEG in Cardiac SurgeryHow can I make a difference in Trauma

THROMBIN

FIBRINOGEN

PLATELETS

Clotting Factors

Thrombin

PlateletsFibrin

Clot

Activation Activation

Plasmin

Clot Breakdown

Platelets

• PTT (partial thromboplastin time)

• PT (prothrombin time)

• Platelet Count (CBC)

aPTT measures the integrity of the intrinsic system (factors XII, XI, VIII, IX) and the common pathway.

Prothrombin time is specific to factors VII, V, X, Prothrombin and Fibrinogen.

How effective is this test and what does it tell us? •Platelet function•Some of our clotting factors

It is at BEST a very crude haemostatic test.

Not really very accurate test and to many variables.

How is it the test performed?

TEG: Native TEG Kaolin TEG Heparinase TEG Platelet Mapping

ADP, Arachodonic Acid, Reptilase(XIII) “V” Curve Rapid TEG “Tissue Factor” I-stat: pH,PCO2,PO2,Na,K,iCa,Glu,Hct,Hb,HCO3,BE, SaO2.

Devolopment and History of the TEG.

1948 Birth of the TEG in Germany Hellmut Harter.1960’s Seen on the surgery front in the USA.Whole blood assay for blood clot analysis.TEG Device:

BleedingThrombosis

Strength StabilityRate

TEG Analyzer Whole blood analysis

Initiation of clotClot developmentClot strengthClot lysis

Information generatedCoagulation pathway

functionFibrinogen functionPlatelet functionFibrinolysis

Platelet function

Clot strength (G)

Clotting time

Clot kinetic

s Clot stability Clot

breakdown

Time (min)

Am

plitu

de (m

m)

US Patent 6,787,363

U.S. Patent 6,787,363

30 min

30 min

30 min

Bleeding Pt

Plain cup

5.8 2.2 59.1 0.0 56.2 6.4 *2.0* *0.4* -1.0 55.0

Heparinase cup

Platelet Function : MA

Normal

Abnormally low platelet function“Low MA”

Abnormally high platelet function“High MA”

6.9 7.7 12.9 29.5 25.0 1.7 0.5 -12.4 0.5

Normal

Secondary fibrinolysisLY30 > 7.5%, CI

>3.0)Primary fibrinolysis(LY30 > 7.5%, CI <

1.0)

5.8 6.0 1.2 74.5 55.5 5.8 63.0 -0.0 63.0

Tracing ComparisonRapid TEG

Kaolin activated(standard TEG)

Native TEG(no activator)

Platelet function (MA) – thrombin generation dependent,not activator dependent…

Trauma Patient: 18 y/o Accidental gunshot

wound to the Left neck.

Rapid TEG contains Tissue Factor (FIII) (tissuethromboplastin)

Rapid TEG

V-curve measure of the area under the curve represents the rate and production of Thrombin. Remember THROMBIN is the center of the clotting world.

•MASSIVE TRANSFUSION PROTOCOL(MASSIVE HEMORRAGE PROTOCOL)

•HEAD INJURIESRich in Tissue Factor (FIII)

•Pregnant MothersRich in Tissue Factor (FIII)

USE OF R

ECOMBIN

ANT FACTOR F

VIIA

(THESE A

RE OFF L

ABEL USES W

HEN USED IN

TRAUM

A)

Any and all question?