Early and individualized goal-directed therapy for trauma-induced coagulopathy

Major brain injury and uncontrolled blood loss remain the primary causes of early trauma-related mortality [1-3]. One-quarter to one-third of trauma patients exhibit trauma-induced coagulopathy (TIC) [4,5], which is associated with increased rates of massive transfusion (MT) and multiple organ failure (MOF), prolonged intensive care unit and hospital stays, and a four-fold increase in mortality [4]. Most patients with coagulopathy also have uncontrolled bleeding, and early diagnosis of the underlying coagulation disorder is paramount for effective treatment.One major challenge in treating severely bleeding trauma patients is to determine whether the blood loss is attributable to surgical causes or coagulopathy. If the patient is coagulopathic, it is paramount to characterize the cause of the coagulopathy and whether thrombin generation is impaired or clot quality or stability is diminished. Recent data suggest that whole-blood viscoelastic tests, such as thromboelastometry (ROTEM？, Tem International GmbH, Munich, Germany) or thrombelastography (TEG？, Haemonetics Corp., Braintree, MA, USA) portray trauma induced coagulopathy (TIC) more accurately and substantially faster than standard coagulation tests [6-8]. There is increasing evidence that these coagulation monitoring devices are helpful in guiding coagulation therapy for heavily bleeding trauma patients according to their actual needs [9].The intention of this review is to examine the concept of individualized, early, goal-directed therapy for TIC, using viscoelastic tests and targeted coagulation therapy. In addition, the AUVA Trauma Hospital algorithm for managing TIC is presented.Fast, reliable diagnosis and characterization of TIC is important. Standard coagulation tests (e.g. prothrombin time [PT], international normalized ratio [INR], prothrombin time index [PTI] and activated partial thromboplastin time [aPTT]) fail to accurately describe the complex nature of TIC for several reasons [4,5]. In vivo coagula