Transcript 11 th Annual Trauma Symposium March 12, 2011 University of

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 Trauma
A. 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
 Experience
 Use of the TEG in Cardiac Surgery
 Similarities between Cardiac Surgery/ Trauma
 Lessons learned with TEG in Cardiac Surgery
 How can I make a difference in Trauma
Clotting Cascade
THROMBIN
FIBRINOGEN
PLATELETS
Coagulation Process
Activation
Clotting
Factors
Platelets
Activation
Plasmin
Clot Breakdown
Thrombin
Fibrin
Platelets
Clot
Hemostasis Components
Interaction and Balance
Traditional Lab Test:
• PTT (partial thromboplastin time)
• PT (prothrombin time)
• Platelet Count (CBC)
Traditional testing: Partial thromboplastin time. (PTT) Intrinsic system.
aPTT measures the integrity of the intrinsic system (factors XII, XI, VIII, IX) and the common pathway.
Traditional Testing: PT (prothrombin time) Extrinsic system
Prothrombin time is specific to factors VII, V, X, Prothrombin and Fibrinogen.
Ivy Bleeding time:
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?
POC: Point of Care Testing:
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.
TEG: Thrombelastograph
Hemostasis System:
 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:
Defining the Position
Looking at Clot Function
Bleeding
Thrombosis
Rate
Strength
Stability
TEG Analyzer
 Whole blood analysis




Initiation of clot
Clot development
Clot strength
Clot lysis
 Information generated
 Coagulation pathway
function
 Fibrinogen function
 Platelet function
 Fibrinolysis
TEG Technology
TEG Tracing
Amplitude (mm)
Clot
kinetics
Clot stability
Clot breakdown
Clotting
time
Platelet function
Clot strength (G)
Time (min)
TEG decision tree
US Patent 6,787,363
U.S. Patent 6,787,363
“Normal”
®
TEG
30 min
Tracing
Prothrombotic TEG Tracing
30 min
Hemorrhagic TEG Tracing
30 min
Bleeding Pt
Heparin Effect
Heparinase cup
Plain cup
5.8
2.2
59.1
0.0
56.2
6.4
*2.0*
*0.4*
-1.0
55.0
Platelet Function : MA
Abnormally high platelet function
“High MA”
Normal
Abnormally low platelet function
“Low MA”
6.9
7.7
12.9
29.5
25.0
1.7
0.5
-12.4
0.5
Fibrinolysis – LY30
Secondary fibrinolysis
LY30 > 7.5%, CI >3.0)
Primary fibrinolysis
(LY30 > 7.5%, CI < 1.0)
Normal
5.8
6.0
1.2
74.5
55.5
5.8
63.0
-0.0
63.0
Tracing Comparison
Rapid 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 INJURIES
Rich in Tissue Factor (FIII)
•Pregnant Mothers
Rich in Tissue Factor (FIII)
Clotting Cascade
Any and all question?