Robert Klemisch, MD,
Washington University in Saint Louis School of Medicine
Seattle, Washington
Disclosure information not submitted.
Jordan Kirsch, DO
Instructor of Surgery
Washington University School of Medicine, United States
Disclosure information not submitted.
Shumaila Khawja, MD
Instructor of Surgery
Washington University School of Medicine, United States
Disclosure information not submitted.
Matthew Schechter, MD
Assistant Professor of Surgery
University of Miami, United States
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Mark Hoofnagle, MD, PhD
Assistant Professor
Washington University School of Medicine, United States
Disclosure information not submitted.
John Mazuski, MD, PhD, MCCM
Professor of Surgery
Washington University in Saint Louis SOM, United States
Disclosure information not submitted.
Title: ROTEM versus Conventional Assays in Prediction of Worsening Traumatic Intracranial Hemorrhage
Introduction/Hypothesis: Rotational thromboelastometry (ROTEM) is a viscoelastic assay that provides an overall assessment of clotting. Conventional coagulation assays (CCAs) including international normalized ratio (INR), partial thromboplastin time (PTT), and platelet count are traditionally used to assess coagulopathy, but only test portions of the clotting cascade. We hypothesized that viscoelastic assays would better predict worsening of traumatic intracranial hemorrhage (ICH) than CCAs.
Methods: We performed a retrospective review of patients at a Level I trauma center between 1/1/2019 and 6/30/2020 who had ICH (including subdural, epidural, subarachnoid, intraparenchymal, or intraventricular hemorrhage), had ROTEM and CCAs obtained on arrival, and had follow up CT or MRI during their hospitalization. Radiology reports were reviewed to identify interval worsening of ICH versus stable or improved ICH. Cases were excluded if a craniectomy was performed prior to follow up imaging.
Results: A total of 202 cases meeting inclusion criteria were identified; 36 patients who had a craniectomy prior to follow up imaging were excluded. Of the remaining 166 cases, 29 (17.5%) died and 137 (82.5%) survived to discharge. Worsening ICH was observed in 81 patients (48.8%) and stable or improved ICH was noted in 85 (51.2%). Of CCAs, only INR ( >1.2) was significantly associated with worsening ICH with an odds ratio (OR) of 3.6 (95% CI 1.6-7.7). PTT >37 (OR of 3.0, 95% CI 0.8-11.7) and platelet count < 150 (OR of 2.5, 95% CI 0.9-7.0) were not significant. No ROTEM value was significantly associated with increased odds of worsening ICH (clotting time >60s OR 1.6, 95% CI 0.8-3.2, alpha angle < 65 OR 1.6, 95% CI 0.7-3.8, maximum amplitude < 53 OR 1.2, 95% CI 0.4-3.5, and lysis at 30 min < 85% OR 0.3, 95% CI 0.01-8.4).
Conclusions: In this cohort of patients with traumatic ICH, ROTEM was no better, and less predictive, than CCAs in identifying patients at risk for worsening hemorrhage. Further study is needed to better identify those risk factors for ICH expansion that may be useful for better targeting interventions to reverse coagulopathy in these patients.