ETD

• TEG; trauma
• thromboelastography

Introduction Trauma-induced coagulopathy (TIC) is a complex, early derangement of hemostasis that contributes substantially to morbidity and mortality in
severely injured patients. Over the last decade, viscoelastic hemostatic assays
(VHAs), including thromboelastography (TEG), have been proposed as tools to
enable goal-directed, physiology-based resuscitation in trauma. However, evidence
regarding their real-world clinical impact remains conflicting, particularly in mature
trauma systems where early empirical strategies—such as tranexamic acid administration and fibrinogen supplementation—are routinely implemented. This study
aims to evaluate the role of TEG in contemporary trauma care by analyzing five
years of experience with a TEG-guided resuscitation protocol in a Level I trauma
center, focusing on its utilization, diagnostic yield, and association with transfusion
requirements and mortality.
Methods We conducted a retrospective observational study including all trauma
patients who underwent TEG analysis in the Emergency Department between October 2019 and December 2024. Demographic data, injury characteristics, physiological variables, conventional coagulation tests, TEG parameters, administered
therapies, transfusion requirements, and outcomes were extracted from the electronic health record. Trauma severity was assessed using the Injury Severity Score
(ISS). Associations between TEG parameters and transfusion need (>=3 units of
packed red blood cells in the Emergency Department) and 30-day mortality were
explored using univariable logistic regression and receiver operating characteristic
(ROC) curve analysis. The local Early Coagulation Support (ECS) protocol and its
interaction with TEG-guided strategies were analyzed descriptively.
Results Despite the long-standing availability of a TEG-guided resuscitation protocol, TEG was infrequently used to actively guide transfusion decisions. The majority of trauma patients, including those with high ISS, did not experience significant
hemorrhage, and transfusion requirements were generally low; only a small subset
required >=3 units of packed red blood cells in the Emergency Department. Early
activation of the ECS protocol frequently preceded the availability of TEG results,
with most patients receiving tranexamic acid and, when indicated, fibrinogen empirically. Overt hyperfibrinolysis on TEG was rare. Among viscoelastic parameters,
functional fibrinogen clot strength (FF-TEG MA) showed the strongest association
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with both transfusion requirement and mortality and demonstrated good discriminative performance on ROC analysis. In contrast, clot initiation parameters were more
closely related to markers of shock and physiological derangement. These findings
suggest that, in a modern trauma system characterized by early empirical hemostatic
support, the overall burden of clinically relevant TIC is limited. Consequently, routine use of TEG in all trauma patients yields little actionable information. However,
a distinct subgroup of patients exhibited persistent coagulopathy on TEG despite
early standardized interventions and did not receive targeted, viscoelastic-guided
correction. In this context, TEG appears most valuable as a selective tool to identify residual or occult coagulopathy, particularly fibrinogen-related clot weakness,
rather than as a universal screening modality.
Conclusions In contemporary trauma care, the clinical utility of TEG lies not in
its indiscriminate application but in its targeted use for selected high-risk patients.
Functional fibrinogen assessment emerges as the most informative viscoelastic parameter, with potential implications for individualized resuscitation strategies. Future efforts should focus on refining patient selection, optimizing integration with
early coagulation support pathways, and aligning viscoelastic thresholds with evolving trauma phenotypes to fully realize the potential of TEG-guided resuscitation.