Trauma-induced coagulopathy and ROTEM

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	Matthieu, 

	We are in the process of incorporating ROTEM into our centre (based
upon the recommendation of a group of us - primarily our Director of
Trauma).  The intention is for 3 machines (1 in the major trauma
operating room, 1 on the ITU and the other in the ED).  The third in
the ED is a little contentious.  The reason for this is not just for
trauma use (bleeding patients need urgent haemorrhage control in a
more appropriate place - wherever that place is - but usually the
operating room for Factor 14).  ROTEM is now being instigated for
other non-trauma reasons as well.  The other benefit that we have of
an analyser in the ED is for the small number of patients who spend
too long in the ED with ongoing bleeding - or even enters the
resuscitation room at all without going straight to the operating
room.  Our trauma lead in the ED didn't want one - she believes
aggressively in early surgical control etc. but this would be useful
to educate and persuade the few less well-informed clinicians who may
(but shouldn't) need convincing that Factor 14 is required to stop the
bleeding.  We had some interesting discussions over this - which was
enlightening.  

	Whoever can operate the machine runs the analysis.  There are some
of us who are surgeons, others intensivists, others anaesthetists,
others emergency medicine physicians etc.  Whoever has the skill
should operate the machine.  Certain scenarios (such as trauma) tend
to dictate which individuals will operate the machine.  This is
usually whoever has activated the Massive Trauma Haemorrhage Protocol
in our centre or whoever is leading the Damage Control Resuscitation
Blood Product administration (usually the same person).  

	I have only ever used whole blood with ROTEM machines. 

	Most of us probably always perform an APTEM test (at least I do). 
Trauma patients should always have an APTEM to look for
hyperfibrinolysis (which I am great believer in).  Stopping the
hyperfibrinolysis with antifibrinolytics is usually necessary.  Here
you can guide therapy according to a more representative assay (which
viscoelastical assay of whole blood is – albeit not perfect). 

	Repeating the test varies depending upon the scenario.  I usually
repeat it every 30 mins in the early resuscitation stages or more
frequently if after rapid administration of extensive volumes of blood
products.  Later on, the assay can be run less frequently (either
every 12 hours or just daily) until "normal". 

	We have a Massive Trauma Haemorrhage Protocol specifically for
trauma patients - although I have been known to use these for
emergency surgery patients as well.  At the moment, transfusion
therapy of products does not revolve around ROTEM assay results.  With
the changeover to using ROTEM analysers, it is anticipated that this
will shortly be revised in the next reviewed version of the Massive
Trauma Haemorrhage Protocol.  

	Regards, 
	Matthew 
	Dear list members. 
	The hematology lab in my hospital recently bought a ROTEM machine
and I would like to implement its use for the management of severe
bleeding in trauma patients. I have some practical question for those
already using it, your input will be welcome.  
	1) Where is the ROTEM located? In the ER? OR? Central laboratory? 

	2) Who operates it? 

	3) Do you use native whole blood sample or citrated blood sample? 

	4) What activators/inhibitors do you use, specifically do you
perform an APTEM test? 

	5) How often do you repeat the test in a given patient? 

	5) Have you established a protocol/algorithm for haemostatic therapy
(PRBC, FFP, platelets, cryoprecipitate, prothrombin complex
concentrate, antifibrinolytics) based on the ROTEM test results? If
yes, could you share it with me?  
	Thank you in advance. 
	Matthieu Gensburger

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