Skip to main content
. Author manuscript; available in PMC: 2022 May 15.
Published in final edited form as: Nat Rev Dis Primers. 2021 Apr 29;7(1):30. doi: 10.1038/s41572-021-00264-3

Fig. 7 |. Examples of goal-directed algorithms for haemostatic resuscitation.

Fig. 7 |

There is substantial variation in management algorithms for early, hypocoagulable trauma-induced coagulopathy (TIC) throughout the world. These algorithms are designed for the general trauma patient. Isolated traumatic brain injury (TBI) provokes a unique TIC phenotype and, therefore, may warrant TBI-specific blood product thresholds for thromboelastography (TEG) and rotational thromboelastometry (ROTEM). a | An example of a US goal-driven approach for a patient at risk of a massive transfusion. Resuscitation is initiated with a balanced blood product strategy with a focus on reversing haemorrhagic shock. In many institutions this consists of a plasma, platelet and RBC formula at a ratio of 1:1:1 with some centres using a plasma to RBC ratio of 1:2, and more recently some have employed low-titre type O-positive whole blood. Regardless of the initial ratio, crystalloids are not administered until shock is reversed, and calcium chloride is given empirically. RBC are continued to maintain haemoglobin >10 g/dl. A rapid TEG measurement is obtained as soon as possible to guide subsequent blood product and tranexamic acid (TXA) administration, according to thresholds derived from clinical studies. If the patient requires >4 RBC during the first hour and TEG results are unavailable, cryoprecipitate and platelets are delivered. b | Examples of algorithms used in some European countries. Isotonic crystalloids and vasopressors are begun initially, and supplemented with fibrinogen and RBC or plasma and RBC at a ratio of 1:2 in the patient at risk of a massive transfusion. TXA is given to all patients, and calcium is corrected according to laboratory testing. RBC are continued to maintain haemoglobin >7 g/dl. Blood products are subsequently provided according to a goal-directed platform based on either ROTEM or conventional coagulation assays. ACT, activated clotting time; aPTT, activated partial thromboplastin time; CCA, conventional coagulation assay; LY30, percentage reduction in the area under the curve at 30 min after MA in TEG; MA, maximum amplitude; PT, prothrombin time; RBC, red blood cell; SBP, systolic blood pressure; VHA, viscoelastic haemostatic assay.